HospitalInspections.org

Based on hospital policy and procedure review, medical record reviews and staff interviews, the facility failed to administer medication as ordered and according to hospital policy for 4 of 5 sampled diabetic patients (#7, 8, 2 and 3).

The findings include:

Review of the facility policy #10-30 "High Alert Medications and Patient Safety" revised July 2012 revealed "The Institute for safe Medication Practices has identified the following medications to have a high risk for causing injury when misused and are referred to as high-alert medications. The medications identified as high-alert at (name of hospital) are: insulin ... Based on identified risk factors the following strategies are suggested for increasing patient safety with respect to these high alert medications. Insulin: Before insulin is administered, a second nurse should perform an independent double-check of the insulin order and dosage ...."

1. Open medical record review on 05/22/2014 of Patient #7 revealed an 83 year-old female admitted on 05/16/2014 with altered mental status. Review of the record revealed a physician's order dated 05/16/2014 at 2025 for bedside glucose monitoring before meals and at bedtime. Review of the record revealed a physician's order dated 05/16/2014 at 2027 for humalog/novolog sliding scale insulin three times a day using the following scale: 0 units for BSG (bedside glucose) of 0 - 149; 1 unit for BSG of 150 - 200; 2 units for BSG of 201 - 250; 3 units for BSG of 251 - 300; 4 units for BSG of 301 - 350; and 5 units for BSG of 351 - 400. Review of the record revealed a BSG result of 228 on 05/16/2014 at 2300. Review of the record revealed the patient was administered 3 units of humalog insulin. Further review revealed there was no co-signature of another nurse verifying the correct dosage was administered. Review of the record revealed a BSG result of 159 on 05/19/2014 at 0700. Review of the record revealed the patient was not administered insulin. Review of the record revealed a BSG result of 205 on 05/21/2014 at 0700. Review of the record revealed the patient was administered 1 unit of humalog insulin. Further review revealed there was no co-signature of another nurse verifying the correct dosage was administered.

Interview on 05/22/2014 at 1005 with RN #1 (the primary nurse that administered insulin to Patient #7 on 05/21/2014 at 0700) revealed the patient's BSG was 205 and she should have received 1 unit humalog insulin. The nurse stated "I think I gave 2 units, but only documented 1 unit. I really can't remember. Yes I think a second nurse is supposed to check the insulin prior to administration. I never document a second nurse check."

Interview on 05/22/2014 at 1000 with RN #2 (a nursing educator) revealed the patient should have received 2 units of humalog insulin for a BSG of 228 on 05/15/2014 at 2300. Interview confirmed the nurse failed to administer the dose that was ordered and failed to have evidence that another nurse verified the correct dosage on 05/15/2014 at 2300. Interview revealed the patient should have received 1 unit of humalog insulin for a BSG of 159 on 05/19/2014 at 0700. Interview confirmed the nurse failed to administer the dose that was ordered. Interview revealed the patient should have received 1 units of humalog insulin for a BSG of 205 on 05/21/2014 at 0700. Interview confirmed the nurse failed to administer the dose that was ordered and failed to have evidence that another nurse verified the correct dosage.



27381

2. Medical record review for Patient #8 on 05/22/2014 revealed an admission date of 05/19/2014 with a diagnosis of congestive heart failure and diabetes. Physician's orders, dated 05/19/2014 - 06/16/2014, included bedside glucose (BSG) monitoring with sliding scale insulin coverage four times per day before meals and at bedtime and at 0300 if insulin was administered at bedtime with no insulin coverage at 0300. Review of sliding scale insulin administration and BSG monitoring documentation for 05/19/2014 - 05/22/2014 revealed no evidence of a second nurse double checking the insulin order and dosage for 8 of 8 insulin administrations.

Observation of insulin administration with a registered nurse (RN #1) and the unit Team Leader (RN #3) on 05/22/14 at 1230 revealed the insulin dosage was confirmed by both RNs. Only the RN (RN #1) administering the insulin checked the physician's order.

Interview with the unit Team Leader (RN #3) on 05/22/2014 at 1240 confirmed it is not usual practice for a second nurse to double check the insulin dosage and order. The Team Leader stated the nurses trust each other and insulin is administered by the "honor system."

Interview with the Chief Nursing Officer on 05/22/14 at 1330 confirmed insulin was not administered per facility policy.

Continued medical record review for Patient #8 revealed the BSG on 05/19/2014 at 1100 was 202. Documentation revealed 6 units of Humalog/Novolog insulin was administered. The sliding scale was for BSG of 201 - 250 to administer 4 units of insulin and not 6 units.

Interview with the Chief Nursing Officer on 05/22/2014 at 1330 confirmed insulin was not administered per facility policy or physician's order.

3. Medical record review for Patient #2 on 05/21/2014 revealed an admission date of 06/29/2013. Diagnoses included pain in right hamstring area, diabetes and atrial fibrillation. Review of physician's orders revealed an order dated 07/02/2013 at 1800 for bedside glucose (BSG) monitoring with insulin coverage determined by a sliding scale. BSG were to be performed four times per day before meals and at bedtime with the following schedule: 0700, 1100, 1700 and 2100. Review of sliding scale insulin administration and BSG monitoring documentation for 06/29/2013 at 2022 - 07/08/2013 at 1700 revealed no evidence of a second nurse double checking the insulin order and dosage for 23 of 23 insulin administrations.

Interview with the Chief Nursing Officer on 05/22/14 at 1330 confirmed insulin was not administered per facility policy.

Continued medical record review for Patient #2 revealed the BSG on 07/03/2013 at 1100 was 261. Documentation revealed 2 units of Humalog/Novolog insulin was administered. The sliding scale was for BSG of 251 - 300 to administer 6 units of insulin and not 2 units.

Interview with the Chief Nursing Officer on 05/22/2014 at 1330 confirmed insulin was not administered per facility policy or physician's order.

4. Medical record review for Patient #3 revealed an admission date of 06/09/2013 for diabetic ketoacidosis with a serum glucose of 1048. Physician's orders dated 06/10/2013 included bedside glucose (BSG) monitoring with insulin coverage determined by a sliding scale every two hours. Review of sliding scale insulin administration and BSG monitoring documentation for 06/10/2013 at 1339 - 06/12/2013 at 1100 revealed no evidence of a second nurse double checking the insulin order and dosage for 13 of 13 insulin administrations.

Interview with the Chief Nursing Officer on 05/22/2014 at 1330 confirmed insulin was not administered per facility policy.

Continued medical record review for Patient #3 revealed the BSG on 06/11/2013 at 0900 was 230. Documentation revealed 9 units of Humalog/Novolog insulin was administered. The sliding scale was for BSG of 201 - 250 to administer 6 units of insulin and not 9 units. The BSG for 06/11/2013 at 1200 was 298. Documentation revealed 12 units of Humalog/Novolog insulin was administered. The sliding scale was for BSG of 251 - 300 to administer 9 units of insulin and not 12 units. The BSG for 0500 on 06/12/2013 was 198. Documentation revealed 6 units of Humalog/Novolog insulin was administered. The sliding scale was for BSG of 150 - 200 to administer 3 units of insulin and not 6 units

Interview with the Chief Nursing Officer on 05/22/2014 at 1330 confirmed insulin was not administered per facility policy or physician's order.

NC00091066