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Based on review of hospital policies and procedures, review of the Governing Board Bylaws and meeting minutes, review of internal hospital reports, review of clinical records and staff interviews, it was determined the Governing Body failed to oversee and maintain accountability for the provision of Quality Assurance/Performance Improvement and Nursing Services.

Findings include:

The Bylaws Governing The Board of Trustees of Valley View Medical Center included: "...The primary responsibility and goal of the Boad of Trustees ('Board') is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Company and Company's Board of Directors...thereby facilitating the establishment of policies, the maintenance of quality patient care, and the provision of institutional management and planning, all in a manner that is responsive to the needs of the community area...."

A-263: Quality Assurance/Performance Improvement: (A-286) The hospital failed to conduct a thorough and accurate investigation of an adverse patient event that resulted in a patient death (Patient #4); failed to identify all opportunities for improvement; and failed to implement action plans based on identified opportunities and monitor the effectiveness of the changes; and the hospital's Governing Body failed to ensure adverse patient events were thoroughly investigated and improvement activities for areas identified were implemented and monitored for success.

A-385: Nursing Services: (A-395) The Registered Nurse failed to provide education to the patient about precautions to take after a peripheral angiography and angioplasty (Patient #14); the Registered Nurse failed to obtain a physician's order to remove the sheath from the patient's right femoral artery after a cardiac catheterization (Patient #7).

A-397: the Chief Nursing Officer failed to ensure the nursing staff was experienced, trained, and competent to adequately monitor a post cardiac catheterization patient (Patient #4); and

A-404: the hospital failed to ensure medications were administered in accordance with the physician's order (Patients #15 and #16, and #17).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality and safe health care.

Based on clinical record reviews, review of hospital policies and procedures, review of hospital documentation of quality assurance/performance improvement activities, and staff interviews, it was determined:

A-286: The hospital failed to conduct a thorough and accurate investigation of an adverse patient event that resulted in a patient death (Patient #4); failed to identify all opportunities for improvement; and failed to implement action plans based on identified opportunities and monitor the effectiveness of the changes; and the hospital's Governing Body failed to ensure adverse patient events were thoroughly investigated and improvement activities for areas identified were implemented and monitored for success.

The effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality and safe health care.

Based on review of hospital policies and procedures, clinical record reviews, review of hospital documentation of quality assurance/performance improvement activities, and staff interviews, it was determined:

1. the hospital failed to conduct a thorough and accurate investigation of an adverse patient event that resulted in a patient death (Patient #4); failed to identify all opportunities for improvement; and failed to implement action plans based on identified opportunities and monitor the effectiveness of the changes.

2. the hospital's Governing Body failed to ensure adverse patient events were thoroughly investigated and improvement activities for areas identified were implemented and monitored for success.

3. the hospital failed to develop a system to identify and document omissions of sliding scale insulin (Patients #15, #16, and #17).

Findings include:

1. The hospital's policy "Sentinel Events" included: "...Sentinel Event is an unexpected occurrence involving death or serious physical or psychologist injury, or the risk thereof...Such events are called 'sentinel' because they signal the need for immediate investigation and response...The Sentinel Event Policy applies to events that meet the following criteria: The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition...Root Cause Analysis (RCA): an evaluative process structured to attempt to determine underlying causes of the adverse sentinel event and whether there is a reasonable potential for process improvement to reduce the likelihood of such events in the future. A root cause analysis will be considered acceptable if it has the following characteristics: The analysis focuses primarily on systems and processes, not individual performance...The analysis identifies changes which could be made in systems and processes (either through redesign or development of new systems or processes) that would reduce the risk of such events occurring in the future...The analysis is through (sic) and credible...The root cause analysis will have a completion goal of 45 days from knowledge of the event, must include the following: A determination of the human and other factors most directly associated with the sentinel event, and the process(es) and systems related to its occurrence...A determination of potential improvement in processes of systems that would tend to decrease the likelihood of such events in the future, or a determination, after analysis, that no such improvement opportunity exists...To be credible, the root cause analysis must: Include participation by the leadership of the organization and by the individuals most closely involved in the processes and systems under review...An action plan will be considered acceptable if it: Identifies changes that can be implemented to reduce risk, or formulates a rationale for not undertaking such changes; and Where improvement actions are planned, identifies who is responsible for implementation, and when the action will be implemented, including any pilot testing and how the effectiveness of the actions will be evaluated...Improvement activities should be monitored for effectiveness by the Quality/Risk department in collaboration with respective/involved departments. A written progress report of follow-up activities is to be conducted within six months of the event and reported to the Medical Executive Committee and the governing board through the Quality Council. The follow-up activity will assess (based on applicable standards): The organization's response to additional relevant information obtained since completion of the root cause analysis; The implementation of system and processes improvements identified in the action plan; The means by which the organization will continue to assess the effectiveness of the actions; and The resolution of any outstanding recommendations for improvement...."

Patient #4 was admitted to Valley View Medical Center on 2/12/2014. Documentation in the physician's History and Physical dated 2/12/2014 revealed the patient's admitting diagnoses included Critical anemia; Paraplegia confined to a wheelchair; and Decubitus ulcer of her left hip.

The clinical record included the physician's Discharge Summary which was dictated on 2/16/2014 at 10:19 a.m. The Discharge Summary included: "Patient was supposed to go home yesterday, but she was tachypneic...Patient actually is doing very well. She is not that tachypneic...At this time, she is actually very calm when I examine her. Patient and her husband both were eager to leave. At this time, physical examination is stable. Laboratories are stable. I will discharge patient home for further outpatient followup..."

The patient was not discharged. On 2/17/2014 the patient was taken to the hospital's Cardiac Catheterization Lab at 9:49 a.m. for a cardiac catheterization. The physician attempted "multiple sticks" in the patient's right femoral artery but was not successful in threading the catheter. The procedure was discontinued and the patient was transferred back to her room on the telemetry unit at approximately 10:37 a.m. The physician did not write orders for the post procedure care of the patient's right groin after "multiple" attempts to access her right femoral artery. The patient was found by nursing staff at 1:30 p.m. to be pale, diaphoretic and with a "large hematoma to right thigh and groin." The patient was taken for a CT scan at 2 p.m. At 2:25 p.m. the patient became non response and the Emergency Response Team was called. The patient was transferred to the Intensive Care Unit at 2:58 p.m. Resuscitative efforts were attempted but were not successful and the patient was pronounced dead at 3:18 p.m.

Cross reference Tag A-397 for more specific details on Patient #4 medical diagnosis and hospital course .

The Chief Nursing Officer (CNO) reported on 8/5/2014 that she started at the hospital approximately two months ago and she had not been made aware of this event, the investigation of it, or the outcome. She was unable to access any documentation of the hospital's investigation because the Director of Quality was out ill and she was the only person able to access it. The CNO was eventually able to produce a form with documentation of the hospital's investigation. However; she was not able to produce supporting documentation of follow up of their actions plans. Although the report itself was not dated, the CNO stated it was completed on 3/10/2014. There was no documentation of who participated in the investigation and development of the action plans associated with the findings.

The surveyors' investigation of the incident revealed inaccuracies and omissions in the hospital's investigation report. The hospital's investigation failed to identify that there was not a policy and procedure for the care of patients after a cardiac catheterization procedure that was facility specific and consistently used. The Director of Nursing originally reported on 8/6/2014 that she was unable to locate a nursing policy and procedure for the care of patients after a cardiac catheterization procedure that was in place at the time of the incident or a current policy. However; she later stated she located a policy titled "Nursing Reference Source for Procedures." Documentation in that policy included: "The hospital will provide materials for staff to utilize as references for procedures...The reference source shall include, but not be limited to 'Nursing Procedures' 4th Edition; Lippincott, Williams, and Wilkins." The surveyors requested the procedure(s) for care of patients after a cardiac catheterization from the resource manual, and she provided a copy of "Angioplasty postprocedure care." A review of that policy revealed areas that directed the reader to facility specific policies. For example: "Monitor the patient's vital signs according the patient's condition and at an interval determined by your facility." The Director of Nursing acknowledged the procedure was general and not specific to hospital practice.

Further examples of inaccuracies and omissions in the hospital's investigation were found during the Department's investigation included the following:

Documentation in the hospital's investigation revealed the patient went to the Cath Lab on 2/17/2014 at "0900" (9 a.m.) However; documentation in the clinical record revealed the patient arrived in the Cath Lab at 9:49 a.m.
There was documentation in the investigation report that the patient went back to the Cath Lab a second time for a "brachial approach" which was not correct.
There was a 35 minute discrepancy between the documented time the patient left the cath lab (10:37 a.m.) and the time the patient arrived on the nursing unit (11:23 a.m.) Neither the cath lab staff or the nursing staff could account for the discrepancy.
There was no documentation of nursing care and assessments after the procedure.
There was no physician's order for the care of the site after the procedure.
There was no physician's order for the CT scan after the hematoma was discovered.
Patient #4 died at 3:18 p.m. on 2/17/2014. The patient's clinical record included documentation by a Respiratory Therapist on that date at "19:34" (7:34 p.m.), over four hours later, that a prn order was not administered because: "no sob (shortness of breath) or distress noted."

The hospital's investigation report revealed there was to be a mandatory inservice on "post CCL patient and femostops." The CNO reported during interviews that there was no documentation that the inservices were conducted.

The hospital provided additional reports of investigations of other patient-related significant events in 2014. An event in February 2014 involved a patient who was found by a radiology technician on the floor next to her bed in the ED. The patient reported she had to assist herself into the bed after using the restroom and could not pull the siderail up. She said she passed out and fell out of bed and hit her head. The Action Plan was that the ER Director would address fall risk management in a staff meeting.

Another event in April 2014 involved a patient who required a "STAT" Cesarean section (C-section). The on-call anesthesiologist's response time from the time he was called until the time he arrived was 33 minutes. The hospital's "Decision to incision" time was 45 minutes. The action plan developed was for STAT C-section section drills to be conducted to "...help us identify areas of improvement to make sure we always hit our 'Decision to incision' time of 30 minutes...."

Another event was in May 2014 which involved a 16-hour delay of a blood transfusion from the time it was ordered until the time it was actually administered. The Action Plan included "mandatory education to all nursing units" and monthly "blood transfusion audits" by the lab to measure effectiveness.

The Chief Nursing Officer reported she was not able to provide documentation that the action plans were implemented and monitored to assess the effectiveness of the plans.

2. The Sentinel Events policy also included: "Upon completion of the RCA, a report should be provided to the Chief Executive Officer and the Quality Council for their review and opportunity for additional input regarding the improvement actions recommended. However; any actions deemed to require urgent implementation do not require committee presentation to implement, if approval may result in a delay and subsequent potential for recurrence and patient injury...The report should be forwarded to the Medical Executive Committee and Governing Board from the Quality Council...."

A review of the Governing Board Meeting Minutes thus far in 2014 revealed no documentation that significant events investigated by the Quality Management Department were reported. The CNO reported during an interview on 8/7/2014 that the event involving Patient #4 was on the agenda for the Governing Body's September 2014 meeting, almost seven months after the event. She said it was the hospital's practice not to inform the Governing Body of a significant event until after the investigation was conducted and closed.

3. The hospital's policy titled Medication Variance, Policy #: 14-03, included: "...Medication use shall follow current standards of practice according to hospital policy. All employees have an affirmative duty to complete a report on medication variances and 'near miss' situations...All medication variances and/or adverse drug reactions are reported to the physician and nursing supervisor and facility's designated person responsible for collection and review of such reports within twenty-four (24) hours, unless there is a change requiring medical intervention and added treatment, in which case immediate notification of the physician is required...Any drug which is not given (with the exception of patient refusal of therapy) before the next scheduled dose is considered omitted. Variances may be the result of failure to send the order to pharmacy, failure to dispense the drug, failure to transcribe the drug onto the MAR, absence of the patient from the unit, failure to document, system variances resulting in the absence of the transcription on the MAR, or failure to order a needed dose of medication...."

-Patients #15, #16, and #17's had physician orders for sliding scale regular insulin. Documentation in those clinical records revealed those patients did not receive some of the doses of insulin after fingerstick blood sugars obtained revealed they should have. Cross reference Tag A405 for further details on those patients. There was no documentation in these clinical records as to why the doses of insulin were not administered at those times nor documentation that the physician and patient were notified of the omissions.

The Quality Risk Coordinator and the Nurse Educator reported during interviews on 8/8/2014 that there were no occurrence reports generated related to the medication omissions.

Based on review of clinical records, review of hospital policies and procedures, and staff interviews, it was determined:

A-395 the Registered Nurse failed to provide education to the patient about precautions to take after a peripheral angiography and angioplasty (Patient #14); and the Registered Nurse failed to obtain a physician's order to remove the sheath from the patient's right femoral artery after a cardiac catheterization (Patient #7).

A-397: the Chief Nursing Officer failed to ensure the nursing staff was experienced, trained, and competent to adequately monitor a post cardiac catheterization patient (Patient #4).

A-405: the hospital failed to ensure medications were administered in accordance with the physician's order (Patients #15 and #16, and #17).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality and safe health care.

Based on review of hospital policies and procedures, clinical record reviews, and patient and staff interviews, it was determined for 2 of 22 patients (Patient #14 and #7):

1. the Registered Nurse failed to provide education to the patient about precautions to take after a peripheral angiography and angioplasty (Patient #14); and

2. The Registered Nurse failed to obtain a physician's order to remove the sheath from the patient's right femoral artery after a cardiac catheterization (Patient #7).

Findings include:

1. The hospital reported the current edition of The Springhouse Lippincott Nursing Procedures Manual was used as the reference manual for their nursing department. The hospital provided the surveyors with a copy of the Lippincott Procedures - Angioplasty postprocedure care. Documentation in procedure included a section for Patient Teaching as follows: "Instruct the patient to avoid heavy lifting and strenuous activities after the procedure because they could affect the puncture site." The hospital's home care instructions for Angiography Care After included: "Limit your activity for the first 48 hours. Avoid bending the place where the catheter was inserted."

Patient #14 was admitted to the hospital on 8/6/2014 where she underwent an abdominal aortic angiography with bilateral peripheral angiography and balloon angioplasty and stenting of the left superficial femoral artery.

Documentation in the clinical record revealed she had an uneventful recovery until 8/7/2014 at 10:40 a.m. The nurse's narrative note at that time included: "Called to pt's room. Pt stated was in using toilet and spread legs apart. She is having pain in the rt groin. Assessed rt groin. Groin firm with hematoma forming. Called charge nurse and director to room. Pressure applied and began massaging gt (sic) groin...BP 74/49. At 10:50 a.m. the RN documented the patient was pale and diaphoretic with a BP of 61/45 and heart rate of 97. The Emergency Response Team was called and the patient was transferred to the Intensive Care Unit. A CT scan performed at 11:28 a.m. revealed the patient had developed a 7 cm x 3 cm soft tissue hematoma in the subcutaneous tissues of the anterior and medial aspect of the right thigh.

An interview was conducted with Patient #14 on 8/8/2014 in the ICU. The patient was alert and was able to recall the events surrounding the development of the hematoma. She reported that she spread her legs when she went to the bathroom and felt something wrong in her right groin. The surveyor asked the patient and a family member who was with her during the interview if they received instructions and precautions to take after the procedure? The patient responded that she didn't think so and if she did, she forgot.

There was no documentation in the clinical record that the patient received education on precautions to take after a cardiac catheterization until after the hematoma developed and she was in the ICU.

The CNO acknowledged during an interview on 8/8/2014 that there was no documentation by the nursing staff providing post catheterization education to the patient and family members.

2. Patient #7 had a cardiac catheterization on 7/6/2014 where an angiogram and stent placement were performed. Documentation in the Cath Lab report revealed the sheath in the patient's right femoral artery was "sutured in place." The patient was taken to the Intensive Care Unit after the procedure at approximately 11:30 a.m. A nursing entry in the Patient Care Notes at 7:50 a.m. on 7/7/2014 included: "Right groin sheath removed manual pressure held for 15 min. There was no physician's order in the clinical record to remove the sheath.

The Manager of the Intensive Care Unit reported in an interview on 8/7/2014 that a physician's order needs to be obtained prior to removal of a sheath.

Based on review of policy and procedure and staff interviews, it was determined the Chief Nursing Officer failed to ensure the nursing staff was experienced, trained, and competent to adequately monitor a post cardiac catheterization patient (Patient #4).

Findings include:

The facility policy: "Standards of Care, Department of Nursing Standards of Practice" includes: "...The Registered Nurse, by virtue of ongoing education, performs competently in his/her practice. Standard of Care: The patient can expect to receive competent, qualified, coordinated care based on their identified needs....Standard of practice 1. Functions within current legislation/practice acts and adheres to the hospital philosophy, policies, procedures, and standards of practice at this facility by...2. Demonstrates accountability and responsibility by: a. Clarifies physician's orders when in doubt. b. Displaying good sense of judgment. c. Providing appropriate and effective supervision when delegating activities. d. Seeking help and guidance when unable to function independently. e. Using resource manuals to verify approved procedures. 3. Registered Nurse is accountable and responsible for initiating, delegating and coordinating nursing care within the hospital in accordance with the hospital policies and procedures..."

Patient #4 was admitted to the Medical Surgical/Telemetry Unit of the facility on 02/12/2014, with diagnoses of Critical anemia; Paraplegia; Bedbound; Decubitus ulcer of left hip; polypharmacy resulting in impaired cognition and mood disorder. Chronic back pain; hypothyroidism; and GERD (gastro-esophageal reflux disorder). She was discharged by the internal medicine physician on 02/16/2014. The discharge summary on 02/16/2014, revealed: "...Diagnostic data: The patient had a chest x-ray on admission. The chest x-ray shows no significant cardiopulmonary disease. Patient had an EKG done which also was normal sinus rhythm. Patient had CAT (computed tomography) scan of the head, did not show any acute hemorrhage. During the hospitalization, patient had EKG which shows SVT (supraventricular tachycardia), ____(sic) which has improved with time. Patient had bradyarrthythmia and echocardiogram showed EF (ejection fraction) of 45% to 50% (normal range 55 - 70%), with slight elevated right ventricular systolic pressure of 45. Brief Hospital Course: Patient was admitted. Patient's medications were optimized. Patient has started to improve..." The discharge order was canceled by the cardiology physician on 02/16/14.

The cardiologist did the cardiac catheterization on 02/17/14, at 10:04 a.m. The operative report included: "...The patient was brought into the catheterization laboratory for cardiac catheterization. The patient was draped and prepared in a standard fashion. The patient has a history of paraplegia and difficult pulses. After appropriate palpation and 1+ Xylocaine infiltration, a puncture was made over the right femoral artery. Some blood was obtained. The wire could not be threaded up. Then, this puncture was aborted. A couple of more attempts were made. There was some blood flow and was impossible to negotiate with a guidewire. Also, the attempts were made under fluoroscopic control. They remained unsuccessful. At this point, it was felt perhaps, Dr. _____ is in the house, vascular surgeon, he might help us to get the access. Dr. _____ was called in. He scrubbed and palpated the artery. He has recommended, the pulses are very poor perhaps, this is not going to be successful. He checked also on the left side. Again, the pulses were poor. At this time, the procedure was aborted. It was felt the patient would be brought in later____(sic) for the arm approach. Appropriate hemostasis was obtained. The patient was sent back to her room...."

The cardiology progress note on 02/17/2014, included: "Pt brought to the Cath Lab for Heart Cath. Pt is paraplegic. Poor pulses. Approximately 3 sticks were made. Not successful. Called Dr. _____ ( name of vascular surgeon) to help. He examined the pulses - agreed poor pulses. Maybe I should reschedule for arm approach. Same was done. Pt returned to the room in stable condition...."

The cardiologist did not write any post procedure orders. Patient #4 left the cath lab at 10:37 a.m. and the RN caring for Patient #4 received the patient at 11: 23 a.m. The med/surg nursing staff and the staff in the Cath Lab could not account for the 35 minute discrepancy during the transfer.

RN #1 started the Post Cardiac Catheterization Nursing Assessment form. The assessment includes: "Vital Signs (VS) every 15 minutes x 4; VS every 30 minutes x 4; then VS every 1 hour x 3." The vital sign checks included the patient's Temperature; Heart Rate; Respirations; Blood Pressure; Groin check; Distal Pulses; DP (dorsalis pedis) and PT (posterior tibial). The first 3 sets of vital signs were done at 11:23 a.m.; 11:35 a.m.; and 11:50 a.m. The rest of the assessments were not done including the surgical site assessment; respiratory; neuro; and genitourinary.

The RN assigned to Patient #4 acknowledged in an interview conducted on 08/06/2014, at 09:30 a.m., the cath lab coordinator had come to the patient's room at 12:00 noon to take Patient #4 back to the cath lab. The RN unhooked the vital signs machine at noon but the procedure was delayed until 4:00 p.m. The RN verified she did not do any further vital signs or surgical site assessments (groin checks) until she found the patient turned from lying flat (on her back) onto her right side with her legs pulled up.

Patient (Pt) #4 was paraplegic with a contracture of the left knee. No documentation was found by the RN verifying the time she found the patient; she acknowledged it was between 1:00 p.m. and 1:30 p.m.

The RN nursing note at 13:30 p.m. included: "Pt diaphoretic, pale, charge nurse notified. Large hematoma to right thigh and groin. vitals obtained. 108/64 hr 95 o2 98% on 3 L. Massaged hematoma and pressure applied to right groin. 14:00 (Name of ICU/Cath Lab nurse) RN during cath lab notified and present. Fem stop applied to R groin. Stat CT of groin and pelvis as well as H&H (hemoglobin & hematocrit) ordered. (name of Charge Nurse) accompanied pt to CT ((computed tomography). pt alert and oriented. vitals within appropriate parameters...."

The CT scan impression included: "...Findings are in keeping with a soft tissue hematoma in the medial aspect of the proximal right thigh beginning approximately at the level of the lesser Trocanter and extending caudally. There is a complex attenuating soft tissue mass in the subcutaneous tissues measuring approximately 12 cm (centimeters) x 5.7 cm x 11 cm. There is diffuse soft tissue stranding in the subcutaneous tissues anteromedially within the left thigh. Suprapubic catheter is noted within a nondistended bladder. The examination is marked stat...."

02/17/2014, at 14:25 p.m. Nursing note included: "ERT (emergency response team) called. pt became non responsive b/p 90/64 hr 84, resp 36. weak pulse. ABG (arterial blood gas) drawn. 1444: Narcan administered 1446: second dose Narcan administered (sic) 1448: bp 80/54 1449: transferred pt to icu...."

02/17/2014 15:20 Nursing note revealed: "Pt brought to ICU at 1458 in bed, unresponsive, pulseless although telemetry monitor showed SR (sinus rhythm) with rate of 86. Gasping respirations. Dr ____ (pulmonary intensivist) present. CPR (cardiopulmonary resuscitation) started. See code-arrest flow sheet for details. Pt did not respond to resuscitation and code was stopped at 1518. Pt's husband was present during the code...."

The RN assigned to Patient #4 verified in an interview conducted on 08/06/2014, she had previous post cardiac catheterization care when she had been with her preceptor during orientation. She was new to the facility since 09/03/2013, and had been an RN at a hospice for 6 months previously. She acknowledged she did not continue vital signs and assessments of Patient #4, she revealed she was busy and didn't ask for help.

The Medical Surgical Unit Manager verified in an interview conducted on 08/06/2014, she had a one to one talk with RN#1 and multiple others involved in the incident. She acknowledged Patient #4 was on a speciality bed, and revealed the staff had to get an "L" wrench to take the bed apart to code the patient. She revealed the Unit had not filled out an adverse event report; and she had not documented the discussions, re-training, or review of competency skills in RN #1's personnel file. Review of the performance evaluation of 06/18/14, for RN #1 revealed: "(Name of RN) is self-reliant and highly focused on her patient care. (Name of RN) is quick to identify concerns and reports them promptly. (Name of RN) knows how to seek out advice when solving problems and when needed...Goals: 1) Focus on charting 2) Improve time management skills...."

The Medical Surgical Unit Manager verified they had a lunch and learn scheduled next Tuesday (6 months after the incident), on 08/12/14, to review and educate the nurses on post cardiac catheterization skills.

The Director of Nursing verified in an interview conducted on 08/07/14, the hospital had no facility specific policy and procedure for the monitoring of post cardiac catheterization patients. She acknowledged there were no post operative cardiac catheterization orders found in Patient #4's medical record; and there was no physician's order for the CT scan done after Patient #4's hematoma was discovered.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined for 3 of 22 patients (Patients #15, #16, and #17) the hospital failed to ensure medications were administered in accordance with the physician's order.

Findings include:

The hospital's policy titled Administration of Drugs-General, Policy #13-01, included: "...Drugs shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice...Prior to giving a medication, scan the medication bar code on the eMAR worklist of hospital information system. This will document the date, time and nurse on the eMAR, then give medication to patient. If a medication is held, document on the eMAR with missed dose function in hospital information system and the reason for holding the medication...."

Patient #15 was admitted to the hospital on 8/5/2014 with preliminary diagnoses of tachycardia and diabetes with hyperglycemia.

The physician ordered medications for her inpatient status included an order dated 8/5/2014 for regular insulin to be administered based on the results of her blood glucose levels checked before every meal and at night. The "Moderate Dose" sliding scale was as follows:

For Blood Glucose
-from 60 to 110 give 0 units
-from 110 to 150 give 4 units
-from 151 to 200 give 8 units
-from 201 to 250 give 10 units
-from 251 to 300 give 12 units
-from 301 to 349 give 14 units
-for Blood Glucose above 349, give 16 units

A review of the medication administration records and "point of care" blood sugar fingerstick results from the time she arrived to the medical surgical unit through the morning of 8/8/2014 revealed 3 doses of insulin were not administered as follows:

8/6/2014 at 7:12 a.m. the patient's blood sugar was "197" and should have received 8 units of regular insulin.
8/7/2014 at 7:19 a.m. the patients blood sugar was "122" and should have received 4 units of regular insulin.
8/7/2014 at 11:21 a.m. the patients blood sugar was "271" and should have received 12 units of regular insulin.

There was no documentation the above insulin doses were administered nor documentation as to why it was not given.

The Quality Management Coordinator and the Nurse Staff Educator were present at the nurse's station during the record review and were not able to locate the documentation. They were not aware the insulins had not been administered and were not able to locate an internal hospital report of the medication errors.

Patient #16 had a blood glucose of 114 on 08/06/14 at 07:06 a.m.; 118 on 08/06/14 at 11:30 a.m.; 127 on 08/06/14 at 16:10 p.m.; 120 on 08/06/14 at 20:40 p.m.; 112 on 08/07/14 at 16:02 p.m.; and 131 on 08/08/14 at 06:42 a.m. No insulin was given to Patient #16 when the blood glucose was over 110 per physician order.

The Unit Manager acknowledged the patient refused treatments but no documentation was done saying the patient refused the insulin. No documentation was found the physician was notified the patient did not receive the insulin ordered by the sliding scale.

Patient #17 was admitted to the facility on 08/05/14 with diagnoses: Abdominal pain, right upper quadrant; Diabetes Mellitus; Cholecystitis; and Cholecystectomy on 08/06/14.

Review of the medical record on 08/08/14, revealed a physician order for an Insulin sliding scale: Insulin Regular 100 Units/ml (milliliter) 3 ml vial. For blood glucose below 60, give 0 UNIT...
-from 60 to 110 give 0 units
-from 111 to 150 give 2 units
-from 151 to 200 give 4 units
-from 201 to 250 give 6 units
-from 251 to 300 give 8 units
-from 301 to 349 give 10 units
-for Blood Glucose above 349, give 12 units. Low dose scale.

Patient #17 had blood glucose of 124 on 08/06/14 at 10:06 a.m.; 143 on 08/06/14 at 12:22 p.m.; 141 on 08/06/14 at 17:57 p.m.; and 133 on 08/05/14 at 23:43 p.m. No insulin was given. No documentation was found the patient refused or the sliding scale was on hold.

Patient #17 refused insulin with a blood glucose of 149 on 08/07/14 at 05:55 a.m. No documentation was found the physician was notified.

Patient #17's Blood Glucose was 166 on 08/07/14 at 11:10 a.m. No insulin was given. No documentation the patient refused or the physician was notified.

Patient #17's blood sugar was 171 on 08/07/14 at 15:58 p.m. with 4 Units of insulin given at 17:47 p.m.

Patient #17's blood glucose was 151 on 08/07/14 at 20:50 p.m. with 4 units of Insulin given at 21:32 p.m.

Patient #17's blood glucose was 169 on 08/08/14 at 06:58 a.m. and 164 on 08/08/14 at 11:30 a.m. No Insulin was given and no documentation the patient refused or the physician was notified.

The Director of Nursing verified the nursing staff need to write a medication error report; document if a patient refuses medication and document they notified the physician when a medication is not given.