HospitalInspections.org

Based on record review and interview, the facility failed to ensure medications were administered as physician order in 1 of 5 patient medical records reviewed (ID# 12).

Findings include:

Record review of facility policy titled "Hospital-wide Medication Administration" dated 06/2023, showed the following information:
Policy:
B. Medication shall be administered by licensed personnel in accordance with federal, state of Texas and other applicable rules, laws and regulations governing such acts. This includes physicians, nurses respiratory therapists... That are trained to administer medication in their respective professional area and working within scope of practice.
D.
5. Goal is to administer the medication 60 minutes before or after the scheduled administration time.
6. eMar will be checked daily to ensure all physician orders have been implemented. Nurse will also need to acknowledge the transcription by pharmacists prior to administering any doses.

Medical record for review for patient (ID#12) on 10/18/23 at 12:45 PM showed the following:

Physician Order for Blood glucose Monitoring place on 10/18/23 at 7:46 AM by physician ID (#68). Order was acknowledged 10/18/23 at 8:06 AM.

Physician Order for Insulin Human Lispro, as Directed Low dose Sliding Scale PRN (as needed), Subcutaneous at 7:45 AM.
Low Dose Sliding Scale
Blood Glucose 70-140 Dose 0 Units
Blood Glucose 141-180 Dose 1 Unit

Blood Glucose for patient (ID# 12) at 8:33 AM was recorded as 152.
Blood Glucose for patient (ID#12) at 11:43 AM was recorded as 170.

Medication Administration Record for Patient (ID#12) showed no insulin given 10/18/23.

Interview with Clinical Nurse Manager (ID# 57) on 10/18/23 at 12:48 confirmed that the patient should have received insulin 1 unit based on both blood glucose readings and that it was not given.