HospitalInspections.org

45769

Based on record review and staff interview it has been determined that the hospital failed to ensure an effective transition of a patient from the hospital to a skilled nursing facility for post-discharge care, due to the failure to list the patients insulin on the medication list provided to the skilled nursing facility on the continuity of care form for 1 of 5 patients reviewed who were prescribed insulin upon discharge (Patient ID #1).

Findings are as follows:

The hospital failed to identify the patients insulin regimen on the continuity of care form upon transfer to a skilled nursing facility, (Refer to A-0813).

45769

Based on record review and staff interview it has been determined that the hospital failed to discharge and transfer a patient with the necessary medical information pertaining to a new insulin regimen for 1 of 5 patients reviewed who was prescribed insulin upon discharge to a skilled nursing facility, (Patient ID #1).

Findings are as follows:

A community reported complaint was submitted to the Rhode Island Department of Health on 12/15/2023 alleging that a patient was transferred to the skilled nursing facility with no insulin order.

Record review revealed that Patient ID #1 was admitted to the hospital in November of 2023 with a diagnosis of left emphysematous pyelonephritis (an acute severe necrotizing infection of the kidney) and hepatic encephalitis (a severe infection of the brain). The patient also has a past medical history of diabetes.

Review of the patient's hospital record revealed a medication administration record (MAR) dated December 2023 containing the following insulin administration order:
Insulin Lispro Injection 0-8 units per sliding scale
Dose: 0-8 units
Frequency: 3 times a day with meals
Route: Subcutaneously

Review of the Continuity of Care (COC) form that the skilled nursing facility received at the time of discharge on 12/14/2023, revealed the following information:

"Continue these medications which have NOT CHANGED ...
U-100 insulin syringe ultra fine, 30 gauge x ½ syringe, use 1 new syringe to inject insulin from vial 3 times a day before meals."

The COC form failed to reveal an order or instructions for insulin administration.

During a surveyor interview with the Pharmacy Patient Safety Director on 12/19/2023 at 10:35 AM, he stated that the pharmacy is alerted to review all insulin discharge orders to confirm correct dosage, however, they would not be alerted to complete a medication review if a physician orders insulin syringes without ordering insulin therefore, Patient ID #1's discharge orders were not reviewed.

During a surveyor interview with the patient's attending physician, Employee A, who completed the discharge on 12/19/2023 at 11:00 AM, she confirmed that she completed the patient's discharge, and she ordered the patient's sliding scale of Lispro Insulin. The surveyor then asked the physician to review the discharge orders, and upon her review she acknowledged that she only ordered the insulin syringes three times a day and did not order the Lispro Insulin sliding scale as intended. The physician stated that her intent was to continue the patient on the sliding scale at the skilled nursing facility.

During a surveyor interview with the Assistant Clinical Manager of CO-OP 3, on 12/19/2023 at 1:00 PM, she stated that the nursing staff completes the discharge paperwork which includes the last time the patient received each medication. She confirmed that the nurse does not look at the copy of the COC that is sent to the facility because it is generated from what the physician enters into the computer which is then faxed to the skilled nursing facility. The Assistant Clinical Manager reviewed Patient ID #1's medication reconciliation that was completed by the attending physician and failed to see that insulin syringes were ordered.