HospitalInspections.org

Based on clinical record review and staff interview, it was determined for eight of eight (#1-#8) current in-patients the Behavior Health Unit's Master Treatment Plan was not individualized to meet the medical needs of the patient in that wound care (#2) and diabetes management (#2-#4) were not addressed; the nursing interventions for Patients #1-#8 psychiatric needs were not individualized with no evidence interventions were carried out. The failure to develop the plan of care, implement interventions and reassess the patient's response to the care provided did not assure the goals were met prior to patient discharge. The findings were:

A. Patient #1:
1) Review of the "Multidisciplinary Treatment Plan": Initial Problem list, page 1 of 4, listed Psychotic Symptoms as Problem #1. Review of the "Goals and Intervention Sheet: Psychotic Symptoms" revealed the following interventions listed: Assess for severity of impairment in daily functioning every shift; Monitor for aggressive escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; spend time on a 1:1 basis to establish trust each shift; As tolerance increases, gradually involve patient in small group activities with peers every shift; short, frequent contacts to provide support and reality testing at least three times per shift; monitor desired and untoward effects of prescribed medication every shift; provide medication educations prior to initiation of therapy and as needed during continuation of it at time of each administration; and Educate patient/family regarding disease process two times.
2) Review of the "Nursing Notes" and the "Behavioral Health Nursing Daily Flow Sheet" from 04/25/14 to 05/08/14 revealed there was no evidence each intervention was addressed by the nursing staff.
3) During an interview on 05/08/14 at 0900, the Nurse Manager of BHU confirmed the nursing documentation did not address each intervention of the plan of care.

B. Patient #2:
1) Review of the physician order dated 05/05/14 revealed to culture the abdominal wound and to dress the abdominal wound BID (two times a day).
2) Review of the "Nursing Notes" from 05/05/14 to 05/08/14 revealed there was no description of the wound related to size and color of the drainage.
3) Review of the "Master Treatment Plan" revealed the plan did not address the patient's abdominal wound or diabetes. The plan under problems identified the patient had chronic pain but did not develop goals or interventions.
4) Review of the "Goals and Intervention Sheet: Suicide Thoughts" revealed interventions included were: "Assist patient in developing relapse and crisis plan; Reinforce for specific demonstration of self-control; Monitor and check for medication as prescribed for ingestion "cheeking," etc. at each administration; and observe for behaviors that are precursors to self-destructive acts such as isolating." Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/05/14 to 05/08/14 revealed there was no evidence the above interventions were addressed by the nursing staff.
5) During an interview on 05/08/14 at 1000, the Nurse Manager of BHU confirmed the nursing documentation did not address the interventions listed above and the patient's medical needs were not addressed in the plan of care.

C. Patient #3:
1) Review of the "Master Treatment Plan" revealed the problems identified were depression and suicidal ideation which were also noted on the Master Problem List.
2) Review of the "Goals and Intervention Sheet: Suicide Thoughts" revealed interventions included were: "Assist patient in developing relapse and crisis plan; Reinforce for specific demonstration of self-control; Monitor and check for medication as prescribed for ingestion "cheeking," etc. at each administration; Offer incentives for demonstration of positive behavior and self-control at each observed instance; and monitor and assess for side effects and effectiveness of medications each shift." Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/05/14 to 05/08/14 revealed no evidence the above interventions were addressed by the nursing staff.
3) Review of the "Master Treatment Plan" revealed the plan did not address the patient's diabetes.
4) During an interview on 05/08/14 at 1107, the Nurse Manager of BHU confirmed the nursing documentation did not address the interventions listed above.

D. Patient #4:
1) Review of the "Master Treatment Plan" and "Goals and Intervention Sheet: Psychotic Symptoms" revealed interventions included were: "Monitor for aggressive escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward side effects of prescribed medication every shift. Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/06/14 to 05/08/14 revealed there was no evidence the above interventions were addressed by the nursing staff.
2) During an interview on 05/08/14 at 1300, the Nurse Manager of BHU confirmed the nursing documentation did not address the interventions listed above.

E. Patient #5:
1) Review of the "Master Treatment Plan" and "Goals and Intervention Sheet: Psychotic Symptoms" revealed interventions included were: "Monitor for aggressive escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward side effects of prescribed medication every shift. Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/06/14 to 05/08/14 revealed there was no evidence the above interventions were addressed by the nursing staff.
2) During an interview on 05/08/14 at 1400, the Nurse Manager of BHU confirmed the nursing documentation did not address the interventions listed above.

F. Patient #6:
1) Review of the "Master Treatment Plan" revealed the problems identified were depression and suicidal ideation. Depression was not included on treatment priority list. There was no plan developed for depression.
2) Review of the "Goals and Intervention Sheet: Suicide Thoughts" revealed interventions included were: "Assist patient in developing relapse and crisis plan; Reinforce for specific demonstration of self-control; Monitor and check for medication as prescribed for ingestion "cheeking," etc. at each administration; Offer incentives for demonstration of positive behavior and self-control at each observed instance; and monitor and assess for side effects and effectiveness of medications each shift." Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/04/14 to 05/08/14 revealed no evidence the above interventions were addressed by the nursing staff.
3) During an interview on 05/08/14 at 1600, the Nurse Manager of BHU confirmed the nursing documentation did not address the interventions listed above and there was no plan for depression.

G. Patient #7:
1) Review of the "Master Treatment Plan" revealed the problems identified were suicidal ideation, anxiety, depressed mood and psychotic symptoms. Depressed mood and anxiety was not included on treatment priority list; there was an indication they were referred. The legend for referred reflected to describe in the progress notes the reason for problem being referred. There was no evidence why depressed mood and anxiety were referred.
2) Review of the "Goals and Intervention Sheet: Suicide Thoughts" revealed interventions included were: "Assist patient in developing relapse and crisis plan; Reinforce for specific demonstration of self-control; Monitor and check for medication as prescribed for ingestion "cheeking," etc. at each administration; Offer incentives for demonstration of positive behavior and self-control at each observed instance; and monitor and assess for side effects and effectiveness of medications each shift." Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/06/14 to 05/08/14 revealed no evidence the above interventions were addressed by the nursing staff.
3) Review of the "Goals and Intervention Sheet: Psychotic Symptoms" revealed interventions included were: "Monitor for aggressive escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward side effects of prescribed medication every shift. Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/06/14 to 05/08/14 revealed there was no evidence the above interventions were addressed by the nursing staff.
4) During an interview on 05/08/14 at 1600, the Nurse Manager of BHU confirmed the nursing documentation did not address the interventions listed above.

H. Patient #8:
1) Review of the "Goals and Intervention Sheet: Suicide Thoughts" revealed interventions included were: "Assist patient in developing relapse and crisis plan; Reinforce for specific demonstration of self-control; Monitor and check for medication as prescribed for ingestion "cheeking," etc. at each administration; Offer incentives for demonstration of positive behavior and self-control at each observed instance; and monitor and assess for side effects and effectiveness of medications each shift." Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/03/14 to 05/08/14 revealed there was no evidence the above interventions were addressed by the nursing staff.
2) Review of the "Goals and Intervention Sheet: Psychotic Symptoms" revealed interventions included were: "Monitor for aggressive escalation of psychotic symptoms during each interaction; Assess for presence of hallucinations each encounter while awake; and Monitor desired and untoward side effects of prescribed medication every shift. Review of the "Nursing Notes" and "Behavioral Health Nursing Daily Flow Sheet" from 05/03/14 to 05/08/14 revealed no evidence the above interventions were addressed by the nursing staff.
4) During an interview on 05/08/14 at 1600, the Nurse Manager of BHU confirmed the nursing documentation did not address the interventions listed above.

Based on clinical record review, policy and procedure review and interview, it was determined the nursing staff failed to adhere to the Sliding Scale Insulin Protocol in administering Humalog according to the capillary blood glucose (CBG) result; failed to advance the Sliding Scale Insulin Protocol to the next dosing regimen; failed to administer the sliding scale insulin in accordance with scheduled meal times; and failed to have to two separate nurse signatures on the Medication Administration Record (MAR) to verify the order and dose of insulin for three of three (#2-#4) and current inpatients on the Behavioral Health Unit (BHU) and one (#12) of two (#9 and #12) closed clinical records: The failed practices had the likelihood of effecting the patient's health and safety in the administration of insulin. The findings were:

A: Patient #2:
1) Admission orders on 05/05/14 instructed to use the low dose sliding scale insulin and to monitor CBGs AC (before meals) and HS (hour of sleep). Review of the Sliding Scale Insulin Protocol revealed to use the low dose scale, to check the CBG before each meal and at bedtime, advance to the next higher regimen if within 24 hours: "a. All readings are greater than 140 mg/dl (milligrams/deciliter) AND b. Glucose level is greater than 180 for two (2) Consecutive Readings OR for two (2) Consecutive Readings Decrease to next lower dose regimen if the glucose level is less than 90 two (2) times within 12 hours." Insulin to be administered was Humalog/Novalog.
2) Review of the Blood Sugar and Insulin Flow Sheet from 05/05/14 to 05/08/14 and the MAR revealed the Sliding Scale Insulin Protocol was not advanced to next level as required by protocol as follows:
a) On 05/06/14 at 1100-CBG was 169, at 1600 CBG was 175 (2 Units), at 2000 was 175 (2 Units);
b) On 05/07/14 at 0700-CBG was 174 (2 Units)), at 1100 CBG was 269 (4 Units-the Medium Dose Level required 6 Units), at 1600 was 189 (2 Units-the Medium Dose level required 6 Units) and at 2034 was 216 (3 Units-the Medium Dose level required 5 Units). On 05/07/14 at 1100, the dose of insulin should have advanced to the next level (Medium dose) as there were 4 consecutive CBG levels greater than 140 within 24 hours. As a result of not advancing to the Medium Dose level the subsequent administration of insulin was not correct.
c) On 05/08/14 at 0707-CBG was 194 (2 Units-the High Dose level required 4 Units) and at 1110 was 264 (4 Units-the High Dose Level required 8 Units). On 05/08/14 at 0707, the dose of insulin should have advance to the next level (High Dose) as there were two consecutive CBG readings greater than 180. As a result of not advancing to the High Dose level the subsequent administration of insulin was not correct.
3) During interview on 05/08/14 at 1610, the Director of Quality and Compliance #3 confirmed the Sliding Scale Insulin Protocol was not followed.

B. Patient #3:
1) Review of the physician's orders sliding scale insulin and monitoring CBGs revealed:
a) Admission orders dated 05/05/14 revealed Humalog per sliding scale (low dose).
b) Order dated 05/05/14 at 1536 revealed CBGs AC and HS.
c) Order dated 05/05/14 at 2205 revealed change sliding scale to Medium Dose.
d) Order dated 05/05/14 at 2230 revealed to consult Hospitalist for blood sugar evaluation.
e) Order dated 05/05/14 at 2355 revealed to continue Medium Dose sliding scale insulin and CBGs Q 2 hours.
e) Order dated 05/06/14 at 0315 revealed discontinue (DC) Q2 hour CBGs.
f) Order dated 05/06/14 at 1415 revealed low dose sliding scale insulin and CBGs AC and HS.
g) Order dated 05/07/14 at 1210 revealed Novalog 10 Units now.
h) Order dated 05/07/14 at 1245 revealed increase sliding scale insulin to High Dose.
2) Review of the Blood Sugar and Insulin Flow Sheet and MARs from 05/05/14 to 05/08/14 revealed there was conflict for insulin administration and meal service delivery; there was no order for an additional administration for 10 Units of insulin; and new Sliding Scale Insulin Protocol form was not completed with each change in the regimen from one level to another as follows:
a) On 05/06/14 at 0630 the flow sheet reflected the CBG was 50 and the MAR at 0841 reflected Humalog was not given due to the CBG being 50 "this" morning. At 0820, the flow sheet reflected the CBG was 297 and 7 Units was administered; the MAR reflected 7 units of Humalog was administered at 0930 which was two hours after the meal delivery schedule to the BHU. There was no evidence why the 0630 CBG was drawn or why it was recorded on the MAR at 0841 that no insulin given due to the CBG of 50. During an interview on 05/08/14 at 1643, the Director of Quality and Compliance #1 called the BHU for the meal delivery times; she was informed the times were: Breakfast-0730, Lunch-1130 and Dinner-1630. Review of the Manufacturer's Directions for use revealed with subcutaneous administration of Humalog "should be given within 15 minutes before a meal or immediately after a meal".
b) On 05/06/14 at 1600, the flowsheet recorded the CBG was 288 with 4 Units of insulin administered; the MAR revealed at 1735 2 Units was administered which was not in accordance with the low dose sliding scale of 4 Units.
c) On 05/07/14 the flow sheet revealed at 1100 the CBG was 499 with 10 Units administered; at 1200 the CBG was 525 with 10 Units administered which corresponded to the now order; and at 1300 the CBG was 365 with 10 Units administered. There was no evidence on the flow sheet why the 1300 CBG was drawn and there was no order to administer another 10 Units of insulin. There was no evidence on the flow sheet a CBG was performed prior to the evening meal. The next recorded CBG on the flow sheet was 69 at 1800.
d) Review of the Nursing Notes dated 05/07/14 at 1320 revealed "Pt's (patient's) blood glucose was 499 before lunch. Stat lab drawn done-result 525. 6 Units given per protocol. AHEC (yellow) called for further orders. Another 10 Units given. Blood glucose rechecked and result 382." Review of the Nursing Notes dated 05/07/14 at 1515 revealed "Pt's blood glucose was 43. Pt treated per protocol."
e) Review of the Sliding Scale Insulin Protocol revealed "When changing from one sliding scale regimen to another, place the new sliding scale Insulin protocol/order sheet on the chart with the new date and time and fax to the pharmacy. Correct the Medication Administration Record for Concurrent Reconciliation." Review of the Sliding Scale Insulin Protocol forms revealed one (Medium Dose Regimen) of the four dose changes did not have a separate Sliding Scale Insulin Protocol.
3) During an interview with Director of Quality and Compliance #1 on 05/08/14 at 1643, it was discussed whether the order on 05/07/14 1245 to increase sliding scale insulin to High Dose insulin was meant for the next meal at 1630. The Director of Quality and Compliance #1 confirmed there was no order for the administration of the insulin at 1300; the order to the High Dose sliding scale was meant to begin at the next meal time at 1630.

C. Patient #4:
1) Admission orders on 05/06/14 instructed to use the low dose sliding scale insulin and to monitor CBGs AC and HS. Review of the Sliding Scale Insulin Protocol revealed to use the low dose scale, to check the CBG before each meal and at bedtime, advance to the next higher regimen if within 24 hours: "a. All readings are greater than 140 mg/dl (milligrams/deciliter) AND b. Glucose level is greater than 180 for two (2) Consecutive Readings OR for two (2) Consecutive Readings Decrease to next lower dose regimen if the glucose level is less than 90 two (2) times within 12 hours." Insulin to be administered was Humalog/Novalog.
2) Review of the Blood Sugar and Insulin Flow Sheet from 05/06/14 to 05/08/14 and the MAR revealed the Sliding Scale Insulin Protocol was not advanced to next level as required as follows:
a) On 5/07/14 at 1100 the CBG was 282-patient refused 4 Units of insulin; at 1200 the CBG was 225-3 Units given; 1610 at 225-3 Units given; and at 2054 the CBG was 207-2 Units given. The insulin given was based on the Low Dose Regimen scale.
b) On 05/08/14 at 0703 the CBG was 204-2 Units given; at 1110 the CBG was 239-3 Units given; and 05/08/14 at 1610 the CBG was 191-2 Units given. The insulin given was based on the Low Dose Regimen scale.

D. Patient #12:
1) Admission orders on 04/23/14 instructed to use the low dose sliding scale insulin and to monitor CBGs AC and HS. Review of the Sliding Scale Insulin Protocol revealed to use the low dose scale, to check the CBG before each meal and at bedtime, advance to the next higher regimen if within 24 hours: "a. All readings are greater than 140 mg/dl (milligrams/deciliter) AND b. Glucose level is greater than 180 for two (2) Consecutive Readings OR for two (2) Consecutive Readings Decrease to next lower dose regimen if the glucose level is less than 90 two (2) times within 12 hours." Insulin to be administered was Humalog/Novalog.
2) Review of the Blood Sugar and Insulin Flow Sheet from and the MAR revealed Humalog insulin was not given according to the Sliding Scale Insulin Protocol and the protocol was not advanced to next level as required as follows:
a) On 04/24/14 at 1100 the CBG was 219-0 Units given. 3 Units should have been administered according to the protocol; at 1600 the CBG was 231-1 Unit was given; at 1647 and 3 Units at 1651 for a total of 4 Units in 14 minutes. The protocol required 3 Units to be given; at 2004 the CBG was 208. At 2105 2 Units were given at 2105 and 2 Units were given at 2120 for a total of 4 Units; only 2 Units should have been given.
b) On 04/25/14 at 1100 the CBG was 214 with 3 Units given. At this point the protocol required the sliding scale to be advanced to the Medium Dose Regimen. The Medium Dose Regimen required 5 Units to be given.
3) During an interview on 05/08/14 at 1510, Director of Quality and Compliance #3 confirmed the sliding scale insulin was not given per the Sliding Scale Insulin Protocol.

E. Review of MARs for Patient #2-#4 and #12 revealed there was no evidence a second nursing staff initialed on the MAR to verify the "5 Rights" of medication was checked. During an interview on 05/08/14 at 1610, Director of Quality and Compliance #3 confirmed there was no evidence a second nurse verified the medication and initialed the MAR for Patient #2. During an interview on 05/08/14 at 1643, the Director of Quality and Compliance #1 confirmed there was no evidence a second nurse verified the medication and initialed the MAR for Patient #3. During an interview on 05/08/14 at 1650, the Director of Quality and Compliance #1 confirmed there was no evidence a second nurse verified the medication and initialed the MAR for Patient #4. During an interview on 05/08/14 at 1510, Director of Quality and Compliance #3 confirmed the insulin was not given per the Sliding Scale Insulin Protocol for Patient #12.

F. Review of the policy and procedure Medication Administration and High Alert Medications revealed for administration of insulin the following:
1) High Alert Medications, page 1 of 3, under policy, "Insulin-Separated in refrigerators or in cubic drawers in Pyxis. Requires double check by 2 nurses (or nurse and physician)".
2) High Alert Medications, page 2 of 3, under procedure, "Administration: Nurses will double check all High Alert Medications before administering except for emergent cases (see below). Double-Checking independently involves:
a) Comparing the label and product in hand versus the written order or pharmacy generated MAR
b) Verifying any calculations for doses that are not dispensed in the exact unit
c) Assuring the setting (rates) of infusion pumps for continuous medication infusions. "
3) High Alert Medications, page 2-3 of 3, under, procedure "A second provider with medication administration training should perform and document a third check by initialing the label and MAR. This check should include: 1) The "5 rights" (right patient, right medication, right dose, right time, right route) ...".
4) Medication Administration, page 2 of 11, under policy, "3. Be alert for any medications that may be on the list of High-Risk medications and be familiar to any precautions that need to be taken (such as having another nurse verify and sign any of these medications). (refer to policy on High-Risk Medications)."