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Based on observation, interview and record review the facility failed to provide care in a safe manner when

a.) A patient was given Novolog (a fast acting insulin) over an hour before receiving the breakfast tray, placing them at risk for a hypoglycemia, low blood sugars and possible death, and was given Novolog an hour and a half after eating lunch placing them at risk for a hyperglycemia, elevated blood sugars and possible organ damage. (Patient #1)

b.) A patient with dysphagia, and was on a Nectar thickened liquids diet, was given unthicken cranberry juice and gelatin, placing them at risk for fluids going into the lungs and possible aspiration pneumonia. (Patient #4)


Findings Include:

a.) During an interview at 9:30 a.m. of 3/21/17, on the medical surgical nursing unit, Patient #1 stated, "...I just got my breakfast, it's two hours late. I'm a diabetic; I need to eat when I need to eat...."

Review of Patient #1's Physician's Orders, dated 3/20/17 reflected a 63 year old male admitted with a diagnosis of Left lower leg cellulitis and Type 2 Diabetes Mellitus.

During an interview in the afternoon of 3/21/27, on the medical surgical unit Staff #7, Certified Nursing Assistant (CNA) stated, "...I delivered patients lunch trays at 12:00 p.m....."

Review of Patient #1's medication administration document dated 3/21/17 reflected the administration of 4 units of Novolog Insulin at 8:00 a.m. The breakfast tray was not delivered until 9:30 a.m.

Review of Patient #1's medication administration document dated 3/21/17 reflected the administration of 6 units of Novolog Insulin at 1:35 p.m. The lunch tray was delivered at 12:00 p.m.

During an interview in the afternoon of 3/21/27, in the administrative conference room Staff #9, Quality Director stated, "...Novolog needs to be administered 5 minutes before meals...it's fast acting..." When asked if the hospital has a policy for the timing for the administration of insulin Staff #9 stated, "No."

b.) An observation on the morning of 3/21/17, on the medical surgical unit in Room #311 revealed Patient #4 sitting next to the bedside table which had five packages of unopened powdered thickener and an unopened container of cranberry juice. The patient was holding and eating a container of gelatin. Patient #4 was observed to be coughing when he ate the gelatin.

Review of Patient #4's Physician's history and physical reflected "...a 77 year old male admitted on 3/20/17 "...here with clinical acute CVA with dysarthria (motor speech disorder), dysphagia (swallowing difficulty), asthenia (weakness)...will get speech, PT and OT. He did have speech eval [sic] upon arrival to the floor, which he failed at beside, so he had barium swallow eval [sic] which he also failed with thin liquids..."

Review of Patient #4's Speech Therapy Note dated 3/20/17 at 2:00 p.m. reflected "...Patient aspirating all thin liquids s/p CVA...Recommendations: 1. Nectar thick liquids due to aspiration of all thin liquids during modified barium swallow study...incomplete airway protection with PO intake ...."

During an interview on the morning of 3/21/17, on the medical surgical unit, when asked if gelatin is on the Nectar thickened liquids diet the DON stated, "I don't think so". When asked if the patient, who is receiving occupational therapy for a CVA (cerebral vascular accident) is expected to open and prepare the thickener himself, the DON stated, "No...the nurse does it...."

Review of the facility provided document from the facility's Manual of Clinical Nutrition of Dysphagia reflected "...Thin liquids include all unthickened beverages...such as clear juices...gelatin and other foods that will liquefy in the mouth within a few seconds...."

During an interview on the morning of 3/21/17 in the facility's kitchen, when asked if a person on a thickened liquids diet could be served gelatin, Staff #12, Dietary Tech stated, "...gelatin is okay..."

During a telephone interview on the morning of 3/21/17 in the facility's dietary manager's office, when asked if there is a menu for patients on thickened liquids Staff #11, Registered Dietitian stated, "We don't have a specific menu for the thickened liquids diet..."

Based on observation, interview and record review the facility failed to develop and enforce the administration of medications according to Accepted Standards of Practice when a patient was given Novolog (a fast acting insulin) over an hour before receiving the breakfast tray, placing them at risk for a hypoglycemia, low blood sugars and possible death, and was given Novolog an hour and a half after eating lunch placing them at risk for a hyperglycemia, elevated blood sugars and possible organ damage. (Patient #1)

Findings Include:

During an interview at 9:30 a.m. of 3/21/17, on the medical surgical nursing unit, Patient #1 stated, " ...I just got my breakfast, it's two hours late. I'm a diabetic; I need to eat when I need to eat...."

Review of Patient #1's Physician's Orders, dated 3/20/17 reflected a 63 year old male admitted with a diagnosis of Left lower leg cellulitis and Type 2 Diabetes Mellitus.

During an interview in the afternoon of 3/21/27, on the medical surgical unit Staff #7, Certified Nursing Assistant (CNA) stated, "...I delivered patients lunch trays at 12:00 p.m. ...."

Review of Patient #1's medication administration document dated 3/21/17 reflected the administration of 4 units of Novolog Insulin at 8:00 a.m. The breakfast tray was not delivered until 9:30 a.m.

Review of Patient #1's medication administration document dated 3/21/17 reflected the administration of 6 units of Novolog Insulin at 1:35 p.m. The lunch tray was delivered at 12:00 p.m.

During an interview in the afternoon of 3/21/27, in the administrative conference room Staff #9, Quality Director stated, "...Novolog needs to be administered 5 minutes before meals...it's fast acting..." When asked if the hospital has a policy for the timing for the administration of insulin Staff #9 stated, "No."

Review of the manufacturer's product use information reflected (https://www.novologpro.com) NovoLog® (insulin aspart [rDNA origin] injection) is an insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus....Administration: NovoLog® should generally be given immediately (within 5-10 minutes) prior to the start of a meal....Hypoglycemia: Hypoglycemia is the most common adverse effect of insulin therapy. The timing of hypoglycemia may reflect the time-action profile of the insulin formulation.... Hypokalemia: Insulin, particularly when given intravenously or in settings of poor glycemic control, can cause hypokalemia...."

Based on observation, interview and record review the facility failed to use the facility's Dietary Manuel as guidance for ordering and preparing a
Patient's diet when a patient, with dysphagia and was on a Nectar thickened liquids diet, was given unthicken cranberry juice and gelatin, placing them at risk for fluids going into the lungs and possible aspiration pneumonia. (Patient #4)

Findings Include:

An observation on the morning of 3/21/17, on the medical surgical unit in Room #311 revealed Patient #4 sitting next to the bedside table which had five packages of unopened powdered thickener and an unopened container of cranberry juice. The patient was holding and eating a container of gelatin. Patient #4 was observed to be coughing when he ate the gelatin.

Review of Patient #4's Physician's history and physical reflected " ...a 77 year old male admitted on 3/20/17 " ...here with clinical acute CVA with dysarthria (motor speech disorder), dysphagia (swallowing difficulty), asthenia (weakness) ...will get speech, PT and OT. He did have speech eval [sic] upon arrival to the floor, which he failed at beside, so he had barium swallow eval [sic] which he also failed with thin liquids ..."

Review of Patient #4's Speech Therapy Note dated 3/20/17 at 2:00 p.m. reflected " ...Patient aspirating all thin liquids s/p CVA...Recommendations: 1. Nectar thick liquids due to aspiration of all thin liquids during modified barium swallow study...incomplete airway protection with PO intake...."

During an interview on the morning of 3/21/17, on the medical surgical unit, when asked if gelatin is on the Nectar thickened liquids diet the DON stated, "I don't think so". When asked if the patient, who is receiving occupational therapy for a CVA (cerebral vascular accident) is expected to open and prepare the thickener himself, the DON stated, "No...the nurse does it...."

Review of the facility provided document from the facility's Manual of Clinical Nutrition of Dysphagia reflected "...Thin liquids include all unthickened beverages...such as clear juices...gelatin and other foods that will liquefy in the mouth within a few seconds...."

During an interview on the morning of 3/21/17 in the facility's kitchen, when asked if a person on a thickened liquids diet could be served gelatin, Staff #12, Dietary Tech stated, "...gelatin is okay..."

During a telephone interview on the morning of 3/21/17 in the facility's dietary manager's office, when asked if there is a menu for patients on thickened liquids Staff #11, Registered Dietitian stated, "We don't have a specific menu for the thickened liquids diet..."

Based on observation, interview and record review the facility's infection control program failed to ensure care was provided in a manner to prevent infections when in four (4) out of (4) patient's Intravenous (IV) tubing and IV catheter sites were not labeled and dated, placing them at risk for infection from being left in and used too long. (Patients # 1, 2, 3 and 4)

Findings include:

Observations made during a tour of the facility's medical surgical unit on the morning of 3/21/17 revealed Patients #1,2 and 4 with Intravenous (IV) tubing that was not labeled when they were hung and Patients#1, 2, 3 and 4 had IV catheter sites that were not labeled when inserted.

Staff #3, RN (Registered Nurse) stated, "...I should have labeled the IV tubing...I should have labeled the IVs when I started them..."

Review of the facility provided document IV Therapy (dated 12/14/15) reflected "...To ensure proper maintenance of intravenous site and material to prevent infection or harm to the patient ....14. Date and time tubing with the appropriate IV tubing label. Record date, time and initials of insertion on the dressing....References: 'Guidelines for the Prevention of intravascular Catheter related Infections, 2011' CDC..."