HospitalInspections.org

Based on document review and staff interview, the nursing executive failed to assure policies for self administration of medications and for medication errors was followed for 1 of 5 patients (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) An order was written on admission for Lantus 44 units at bedtime.
(B) Per the medication administration record (MAR), the patient received 44 units of Novolog insulin at 9:15 p.m. on 5/20/12 by RN #1. Narrative nurses notes states "WAS GIVEN PM INSULIN AND GRABBED WRONG PEN, PULLED UP 44 UNITS OF NOVOLOG AND PATIENT WANTED TO HURRY UP AND GIVE SHOT TO SELF. HE STARTED TO GIVE SHOT AND SAID "THIS LOOKS LIKE NOVOLOG" HE WAS INJECTING SELF AND INFORM TO STOP BY THE TIME THAT WAS SAID..."
(C) The medical record lacked documentation of an order to self administer medication and evidence of patient education and competence per policy.

2. Review of incident/medication error reports for 5/19/12-5/26/12 indicated there was no medication error report generated in the system for patient #1.

3. Facility policy titled "SELF-ADMINISTRATION OF MEDICATION" last reviewed/revised 12/3/10 states under policy statement: "Self-Administration of medications by patients shall be permitted on a specific written order by the authorized prescribing practitioner. Prior to being permitted to self-administer medications, patients must be educated about the medication and determined to be competent to self administer the drugs. Documentation of the training will be recorded in the nursing documentation system.

4. Facility policy titled "MEDICATION ERRORS" last reviewed/revised 12/21/10 states under policy statement on page 1: "Medication errors and potential medication errors shall be reported by the healthcare professional(s) involved in, witnessing, or first discovering the actual or potential errors. Medication event reporting is encouraged and provides (facility #1) with the opportunity to educate and improve the overall medication use system." Under definitions on page 1, the policy states "A. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer....." Page 2 of the policy states under procedure: "A. Medication errors and near miss medication errors must be entered into the hospital's event reporting system. B. Medication errors that reach the patient must be reported to the unit/department manager and communicated to the patient's physician."

5. Staff member #5 indicated the following in interview beginning at 2:50 p.m. on 6/25/12:
(A) The nurse (RN #1) that gave the incorrect insulin to patient #1 indicated to him/her that he/she completed an incident report in writing. RN#1 is an agency nurse and has no access to complete an online medication error/incident report.
(B) There was no order for self administration of medication in the medical record of patient #1 nor was there evidence of patient education and competency per facility policy.

6. Staff member #1 indicated in interview at 4:30 p.m. on 6/25/12 that there was no incident report for the medication error for patient #1.