HospitalInspections.org

Based on observations, records reviewed and interviews the Hospital failed, for one out of ten sampled patients, to administer an order for insulin (a drug that lowers blood sugar) to Patient #1 on two separate occasions resulting in Patient #1 becoming hyperglycemic (high blood sugar) and subsequently entering into a state of diabetic ketoacidosis (DKA-a life-threatening condition that develops when cells in the body are unable to get the sugar (glucose) they need for energy because there is not enough insulin).

The Policy titled Medication Administration Policy, dated 10/2017, states "If a medication is not given, note time, indicate the reason, and notify the 24/7 Critical Result Contact as appropriate."

The "order detail view" screen, dated 03/06/2018 at 9:53 P.M., indicated Patient #1's insulin (blood sugar lowering drug) regimen. On 03/7/18 at 1:16 A.M., Patient #1's insulin regimen displayed instructions to administer Humalog 2 units (a rapid acting injectable insulin) for a routine blood sugar check of 242 (normal blood sugar 70-100 milligrams per deciliter) conducted by Nurse #3. The medication administration record for Patient #1, dated 03/07/18 at 1:16 A.M., indicated that Nurse #3 did not administer Patient #1's dose of short-acting insulin providing the reason, "NPO" (nothing by mouth). The medical record of Patient #1 failed to indicate any documentation that Nurse #3 attempted to contact the provider, or receive approval to hold the sliding scale insulin dose.

The "order detail view" screen, dated 03/06/2018 at 9:53 P.M., indicated Patient #1's insulin regimen. Patient #1's insulin regimen displayed instructions to administer Glargine 5 units (a long acting injectable insulin) scheduled for 5:00 P.M on 03/07/18. The medication administration record for Patient #1, dated 03/07/18 at 7:12 P.M., indicated that Nurse #1 did not administer Patient #1's Glargine providing the reason, "pt NPO". The medical record of Patient #1 failed to indicate any documentation that Nurse #1 attempted to contact the provider or receive approval to hold the long-acting insulin dose.

The Surveyor interviewed Nurse #1 on 03/30/18 at 2:00 P.M. Nurse #1 said she did not administer the Glargine dose scheduled for 03/07/18 at 5:00 P.M. Nurse #1 said she did not contact the physician prior to holding the Glargine.

The "order detail view" screen, dated 03/06/18 at 9:53 P.M. indicated Patient #1's insulin regimen. On 03/7/18, Patient #1's insulin regimen displayed instructions to conduct blood sugar checks every six hours and further instructions that would dictate how much Humalog (a rapid acting injectable insulin) to administer based on the blood sugar result. The medication administration record for Patient #1 indicated that no blood sugar checks occurred between 5:00 PM on 03/07/18 and 8:10 A.M. on 03/08/18.

The Surveyor interviewed Nurse #2 on 04/04/18 at 2:15 P.M. Nurse #2 stated she could not recollect that she missed an order to obtain blood sugar checks every six hours for Patient #1. Nurse #2 stated that the instructions section of the insulin regimen under "order detail view" is to be followed unless otherwise indicated by the provider. The medical record of Patient #1 failed to indicate any documentation of an order to hold blood sugar checks between 5:00 P.M. on 03/07/18 and 8:10 A.M. on 03/08/18.