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Based on policy review, record review, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation: Nursing Services related to the failure of nursing staff to follow hospital policy related to medication administration resulting in a patient receiving the wrong insulin type, and the failure to administer insulin to the correct patient, as well as the failure to follow the standard of practice related to clarifying the order for a high dosage of insulin.
Additionally, the hospital failed complete the orientation and evaluation of Travel Nurses who were involved in insulin medication errors resulting in a clinical intervention other than monitoring for Patient ID #1 and 3. Additionally, the hospital failed to investigate the insulin error for Patient ID #1 per the hospitals policy.

Findings are as follows:

1. The hospital failed to ensure licensed nurses adhere to hospital policies and procedures relative to the failure to complete the orientation and evaluation of Travel Nurses, the failure to investigate an event that included a potential or actual injury to the patient outlined in the "Event Reporting System" policy, and the "Managing High Alert/High Risk Medications" policy related to the failure of nursing staff to co-sign high alert medications at the bedside. (refer to A-398).

2. The hospital failed to provide nursing care in accordance with hospital policies for "Medication Administration" and "Managing High Alert/High Risk Medications" related to the failure to administer a high risk medication to the correct patient, Patient ID #1, the failure to administer the correct dosage of insulin, Patient ID #3, and the failure to administer the correct type of insulin to Patient ID #4. (refer to A-0405).

















45769

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to ensure the orientation and evaluation checklist was completed per hospital process for a Travel Nurse who administered the wrong high alert medication (Employee A), and a Travel Nurse (Employee C). Additionally, the hospital also failed to investigate a medication error per hospital policy which resulted in a clinical intervention other than monitoring for Patient ID #1.

Findings are as follows:

1. A community reported complaint submitted to the Rhode Island Department of Health on 3/2/2023 indicated that Patient ID #1 was administered insulin glargine (Lantus), (a long-acting insulin used to control blood glucose levels), by mistake.

Record review revealed that Patient ID #1 was admitted to the hospital in February of 2023 to the Behavioral Health Unit for increased agitation and combativeness. His/her diagnoses include, but are not limited to, Alzheimer's Disease.

Record review revealed that Patient ID #2 was admitted to the hospital in February of 2023 to the Behavioral Health Unit for evaluation and management of increased agitation.

Record review for Patient ID #2 revealed an order for insulin glargine (Lantus) 34 units to be administered at bedtime.

Record review for Patient ID #1 did not reveal physician orders for insulin glargine (Lantus).

Record review revealed that on 2/14/2023, Patient ID #1 was administered 34 units of Lantus insulin in error by Employee A, Travel Nurse, which was intended for Patient ID #2.

Review of a document titled, "Progress Note" dated 2/15/2023 entered by a provider for Patient ID #1, revealed that after receiving this medication in error, Patient ID #1 was ordered hourly blood glucose checks and one liter of Dextrose 5% in 0.9% Sodium Chloride, (a solution containing glucose) to be administered intravenously at 50 milliliters per hour for a total of 20 hours.

According to the hospital's "RN [Registered Nurse] BH [Behavioral Health] Traveler Checklist 2023", a section titled, "Section 3: Nursing Skills-Medication Administration" presents a checklist with the following activities to be checked off:

"...Bedside medication verification...

Verifying correct patient (two patient identifiers), medication, dose route and time

Verifying correct purpose, reason, response and documentation, identifies allergies...

...Review process for adverse drug reaction, medication error..."

During a surveyor interview on 3/8/2023 at 1:31 PM with the Systems Director of Risk Management, she was unable to provide evidence of a completed "RN BH Traveler Checklist" for Employee A which included medication administration procedures.

1. Review of "RN Traveler Checklist 2023" revealed that Employee C's start date was 2/22/2023 and the only section that was completed on 2/22/2023 was "Introductory Activities."

The checklist further revealed that upon request from the surveyors on 3/15/2023, the following sections were not completed until 3/18/2023, the day after the surveyors exited the hospital:

- "Introductory Activities (unit)
- Equipment (location and use)
- Section 2: Nursing Skills/Communication
- Section 3: Nursing Skills/Medication Administration
- Section 4: Computer Documentation
- Section 5: Shift Documentation
- Section 6: Safety
- Section 7: Bladder Health Management
- Section 8: Behavioral Health Management

During a surveyor interview on 3/15/2023 at 2:11 PM and on 3/16/2023 at 3:45 PM with Employee C, Travel Nurse, he revealed that he received about 6 hours of orientation on his first day of work where he was quickly oriented to the charting system at the hospital and was also educated on the hospital's infusion pumps. He indicated that he shadowed a nurse the rest of his first shift and continued to follow a nurse for his next 2 shifts. He stated that after that he was on his own.

During a surveyor interview on 3/8/2023 with the Chief Nursing Officer/Vice President of Patient Care Services of Charter Care, she was asked how non-employee staff, such as Travel Nurses are oriented and evaluated at the hospital. She indicated that a checklist for Travel Nurses has been created for this process and the leaders in charge of the unit are responsible for completing the Travel Nurse checklist. Additionally, she was unaware that a medication error involving the administration of insulin to the wrong patient had occurred.

2. Review of a hospital policy titled," Event Reporting System" last reviewed on 7/2022 states in part,

"...Procedure...All events will be investigated objectively and in a timely manner including a performance improvement analysis, medical peer review or conducting a root cause analysis when warranted...

...Management Responsibilities...once the event has been assigned and reviewed, the Manager, Director or Supervisor must document a short summary as to what will be done to correct the event...Follow up may include responding to questions from Risk Management...The event should be reviewed within 3 business days...Once the manager has completed all required follow up, the manager/director will sign off the event..."

During a surveyor interview on 3/8/2023 at 1:38 PM with the System Director of Risk Management, she was unable to provide evidence that an investigation of the medication error was thoroughly conducted, evidence that the event was reviewed within 3 business days per hospital policy, or evidence that required follow up was completed by the manager per hospital policy.

During a surveyor interview with the Director of the Behavioral Health Units on 3/8/2023 at 2:10 PM, she stated that she spoke to Employee A on 2/15/2023 in the early afternoon. She revealed that Employee A acknowledged the medication error, however, she did not investigate the error at that time. She was unable to provide evidence that the investigation had taken place or that follow up action was completed.







45769

Based on policy review, record review and staff interview, it has been determined that the hospital failed to ensure that high alert/high risk medications are administered and documented in accordance with hospital policies and Federal and State laws for 4 of 6 patients reviewed who received Insulin, a medication used to help regulate blood glucose (sugar) levels, Patient ID #s 1, 2, 3, and 4.

Findings are as follows:

The hospital's policy titled, "Medication Administration" last revised on 3/2021 states in part,

"...C. Administration and recording of medications:

...p. Identify patient using 2 patient identifiers...scan barcode on patient ID bracelet and scan barcode on medication, then give medication...

...r. Once patient takes the meds, click on SAVE.

s. Complete charting on eMAR (electronic medical administration record) by saving..."

The hospital's policy titled, "Managing High Alert/High Risk Medications" dated 4/2021 states in part,

"Policy

Medications and therapies that are identified as high alert/high risk benefit from a second review to ensure their safe use for our patients...The identified medications will require a co-signature from a second nurse before the dose is administered to the patient...

...Definitions

High-Alert Medications: High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error...

...Co-Check/Co-signature: A Co-signature is the process of having a second health care professional check the medication or therapy for: right patient, right drug, right route, right dose, and right time and co-sign with the administration nurse..."

...Procedure:

...h. All medications that require a co-check/co-signature for documentation need to be checked for the following: right patient, right drug, right dose, right time, right route ...This process requires that both nurses (or nurse and other health care professional) do the checks at the bedside for accuracy. Both must document at the bedside, in MEDITECH [electronic medical record system] or on paper in areas where the eMAR is not available..."

1. A community reported complaint submitted to the Rhode Island Department of Health on 3/2/2023 indicated that Patient ID #1 was administered Lantus, (a long-acting insulin used to control blood glucose levels), in error.

Record review revealed that Patient ID #1 was admitted to the hospital in February of 2023 to the Behavioral Health Unit for increased agitation and combativeness. His/her diagnoses include, but are not limited to, Alzheimer's Disease.

Record review revealed that Patient ID #2 was admitted to the hospital in February of 2023 to the Behavioral Health Unit for evaluation and management of increased agitation.

Record review for Patient ID #2 revealed an order for insulin glargine (Lantus) 34 units to be administered at bedtime.

Record review for Patient ID #1 did not reveal physician orders for insulin glargine (Lantus).

Review of a document titled, "Nurse Notes" for Patient ID #1 dated 2/15/2023 at 12:44 AM entered by Employee A, Travel Nurse, stated in part, "Wrong diabetic PT [patient] given 34 units of Lantus - RN [Registered Nurse] asked PT to confirm [his/her] name and PT did so - PT confirmed wrong name..." This note did not reveal evidence that the patient was wearing an identification bracelet or that the bracelet was scanned per policy prior to administering the Lantus insulin.

Record review for Patient ID #1 revealed an "Addendum" progress note dated 2/15/2023 at 7:25 AM, revealing "Patient given wrong med (Lantus 34 units) in error from another nurse...#22 G [gauge] INT [intravenous therapy] placed in RFA [right forearm]..."

Record review for Patient ID #1 revealed a document titled, "Progress Note" dated 2/15/2023 entered by a provider which stated in part that Patient ID #1 "inadvertently received 34 units of Lantus insulin meant for another patient." Additionally, the note further indicated that after this incident, Patient ID #1 was ordered hourly blood glucose checks and one liter of Dextrose 5% in 0.9% Sodium Chloride, (a solution containing glucose) to be administered intravenously at 50 milliliters per hour for 20 hours.

Review of the Patient ID #1's glucose test revealed a blood glucose level of 88 at 2:05 AM on 2/15/2023 while still receiving Dextrose 5% in 0.9% Sodium Chloride.

Review of the Omnicell (medication dispensing system) transaction report for 2/14/2023 revealed that at 9:00 PM, Employee A removed the Lantus insulin from the Omnicell.

Review of the pharmacy audit sheet administration record revealed that Lantus insulin had only been scanned and signed as given one time on 2/14/2023 at 9:46 PM, despite being administered to both Patient ID #'s 1 and 2 as evidenced by Employee A's progress note and Employee B's interview.

A surveyor interview was attempted on 3/8/2023 at 1:08 PM with Employee A via telephone. He was asked to clarify what had occurred and what led to the medication error involving the administration of Lantus to Patient ID #1. His response was, "I can't really talk about it" and hung up.

During a surveyor interview on 3/8/2023 at 2:50 PM with Employee B, RN, she stated that she co-signed insulin with Employee A for Patient ID #2 at the nurses' station and she thought he went to give it to Patient ID #2. She revealed that between 9:00 PM and 10:00 PM on 2/14/2023, she told Employee A to talk to Patient ID #2 as she/he was "yelling out" that she/he did not receive his/her insulin. She stated that Employee A did not tell her that he gave the Lantus to the wrong patient at that time. She indicated that he stated to her he had not administered the insulin yet and was holding the syringe of Lantus insulin in his pocket. She revealed that at approximately 11:30 PM, when Employee A left for the night, he walked out of the unit and "came right back" to tell her he had incorrectly medicated Patient ID #1 with the Lantus that was meant for Patient ID #2. Employee B was asked if she ever witnessed Employee A administer the dose of Lantus to Patient ID #2, she replied she did not.

Additionally, when asked, as the co-signer, if she confirmed the identity of Patient ID #2 for whom the medication was meant for, she stated, "No." When asked if it is her usual practice not to identify the right patient when co-signing for insulin, she indicated that she only ensures the correct dose is given and stated, "we don't have time to verify that the medication is administered to the right patient."

2. On 3/13/2023, the hospital submitted an incident report to the Rhode Island Department of Health which indicated that on 3/12/2023 Patient ID #3 received 100 units of Insulin Human Lispro, Admelog (a medication used to control blood glucose levels) at 9:28 AM. The report states that at 1:00 PM, a medication error was discovered after Patient ID #3's blood glucose was checked and found to be 26 which necessitated additional clinical interventions other than monitoring.

Record review revealed that Patient ID #3 presented to the Emergency Department in March of 2023 from a nursing home for a mental health evaluation after becoming combative.
Review of Patient ID #3's "Medication Review Report" dated 3/11/2023 from the nursing home stated that she/he was currently receiving the following medication:

"Humalog Kwikpen Subcutaneous Solution Pen Injector 100 unit/ml [milliliter] (insulin Lispro) Inject as per sliding scale:

if 200 - 250 = 2 units
251 - 300 = 4 units
301 - 350 = 6 units
351 - 400 = 8 units
401 - 450 = 10 units
451 - 500 = 12 units
Subcutaneously three times a day for dm [Diabetes Mellitus] notify md [Medical Doctor] if <60 or >450."

Record review of "Emergency Department Notes" for Patient ID #3 dated 3/12/2023 at 4:00 AM entered by Employee C, Travel Nurse, stated "Pharmacist called to confirm patient insulin frequency. RN [Registered Nurse] confirmed patient is taking insulin 3x [3 times] daily."

Review of a hospital document titled, "Reconcile Meds" revealed that on 3/12/2023 at 4:55 AM, Employee D, Physician, "converted" the following "reported" medication into an active order:

"Insulin Lispro 100 unit/Ml Insulin. Pen (Humalog Kwikpen)
100 Unit SQ TID
SLIDING SCALE"

This order did not include the insulin administration parameters as they were outlined in the "Medication Review Report" from Patient ID #3's nursing home as stated above.

Review of the Pharmacy's "Clinical Intervention" report revealed a note entered by Employee E, Pharmacist, at 6:48 AM which stated, "RN confirmed insulin lispro dose (100 units TID) based off patient's facility records." This report failed to reveal evidence that the insulin dose was clarified by the RN with the ordering prescriber.

Review of the "Medication Administration" record revealed that on 3/12/2023 at 9:28 AM, Patient ID #3 was administered 100 units of Insulin Human Lispro Admelog, subcutaneously by Employee F, RN, and cosigned by Employee G, RN. Additionally, Patient ID #3's "Finger Stick Blood Glucose" at the time of this medication administration was 222.

Review of the "Fingerstick Blood Glucose" documentation revealed that on 3/12/2023 at 1:16 PM, Patient ID #3's blood glucose level was 26 milligrams (mg)/deciliter (dL) (normal range 70 - 100).

Further review of the "Fingerstick Blood Glucose" documentation revealed that on 3/12/2023 at 1:25 PM, Patient ID #3's blood glucose level was 22 mg/dL.

Review of the "Medication Administration" record for Patient ID #3 revealed that at 1:00 PM, the scheduled Insulin Human Lispro Admelog dose of 100 units was not administered due to a "Finger Stick Blood Glucose" level of 22.

Record review of the "Emergency Department Notes" dated 3/12/2023 at 1:44 PM stated in part that after Employee F identified a low blood glucose level of 26, she notified the physician and administered 4 ounces of orange juice. The note further states that the patient's blood glucose level was rechecked and noted to be 22. Employee F then indicated with a physicians order she administered 50% dextrose (an intravenous medication used to restore blood glucose levels).

Review of the "Emergency Room Visit Notes" dated 3/12/2023 stated in part,
" ...Progress note - [Interim Medical Director]

...Notified by nurse that Patient's glucose is 26. Patient chart reviewed. It appears patient received 100 units of insulin this morning ..."

Further review of the "Emergency Room Visit Notes" documented by Employee H, ED Physician dated 3/12/2023 stated in part,

...Patient's emergency department course was complicated by patient unfortunately receiving 100 units of subcutaneous insulin this morning, causing [him/her] to become hypoglycemic [low blood glucose] with a glucose of 26 ..."

Additional review of "Emergency Department Notes" dated 3/12/2023 at 2:18 PM stated that the patient's blood glucose level was rechecked and noted to be 89 for which the physician was made aware, and an additional dose of 50% Dextrose was administered to the patient.

During a surveyor interview on 3/15/2023 at 2:11 PM and on 3/16/2023 at 3:45 PM with Employee C, Travel Nurse, he stated that on the early morning of 3/12/2023, a pharmacist called the Emergency Department who asked him how often Patient ID #3 was taking the insulin. He stated that he checked the nursing home rehabilitation paperwork and only confirmed the frequency of insulin, which was to be administered three times daily. He stated that he did not check the patient's hospital medical record and only looked at the nursing home rehabilitation medication list. When asked about the dose of insulin, he stated that he did not look at anything else about the order, other than frequency, since he was not going to administer the insulin, so he did not think about it.

During a surveyor interview on 3/15/2023 at 2:27 PM with Employee F, RN, she stated that she was not told in report by Travel Nurse, Employee C that the pharmacy had called earlier questioning the insulin order for Patient ID #3. She indicated that the patient's next dose of insulin was due at 1:00 PM and began to think about the dose being too much so she checked the blood glucose level and found it to be 26. When asked if she had any questions about the 100 units of Admelog she administered initially, she stated that she did not, nor did she speak to a physician about it. Additionally, she revealed that the nurse who cosigned insulin administration with her, Employee G, did not question the insulin dose either.

During a surveyor interview on 3/15/2023 at 10:30 AM with the Emergency Department Nurse Manager, she was unable to provide evidence that nursing staff questioned the 100-unit dose of insulin ordered three times a day for Patient ID #3.

3. On 3/13/2023, the hospital submitted an incident report to the Rhode Island Department of Health which indicated that on 3/13/2023 Patient ID #4 accidentally received 30 units of Admelog insulin instead of Lantus insulin which was ordered. The report states that this medication error necessitated clinical interventions other than monitoring which included the administration of 50% dextrose (an intravenous medication used to restore blood glucose levels) and a continuous infusion of Dextrose 5%, (a solution containing glucose).

Record review revealed that Patient ID #4 was admitted to the hospital in March of 2023 due to respiratory failure and sepsis related to pneumonia and altered mental status.

Review of the Pharmacy "Order" report revealed the following two orders for Patient ID #4:

1. Lantus 30 units subcutaneously daily in the morning

2. Admelog sliding scale before meals and at bedtime with the following parameters:

"Blood Glucose <80 No Insulin
Blood Glucose 80 - 100 No Insulin
Blood Glucose 101 - 150 No Insulin
Blood Glucose 151 - 200 2 units
Blood Glucose 201 - 250 4 units
Blood Glucose 251 - 300 6 units
Blood Glucose 301 - 350 8 units
Blood Glucose 351 - 400 10 units
Blood Glucose >400 12 units and CALL MD [Medical Doctor] ..."

Further review of the Pharmacy "Order" report for Admelog insulin revealed that on 3/13/2023 the scheduled 7:30 AM dose was not administered to Patient ID #4 due to a blood glucose level of 138.

The report then revealed that on 3/13/2023 the patient received a dose at 9:08 AM of Admelog insulin 30 units instead of the scheduled dose of Lantus insulin 30 units as ordered. The dose administered was documented under the Admelog sliding scale insulin order on the medication administration record by Employee I and co-signed by Employee J.

Review of "Nurse Notes" dated 3/13/2023 at 9:59 AM entered by Employee J states "30 units Admelog given in place of Lantus. MD notified. 5% dextrose at 75 ml's [milliliters]/hr [hour]. 50% dextrose 50 ml amp [ampule] administered."

Review of a "Progress Notes" for Patient ID #4 dated 3/13/2023 entered by Employee K, Physician Assistant, at 2:52 PM states, "...Patient given a dose of increased Admelog on 3/13, provided with 8 hours of D5 ..."

During a surveyor interview on 3/15/2023 at 11:45 AM with Employee J, she revealed she grabbed what she thought was the Lantus insulin vial from another employee and handed it to Employee I, who then "drew up" 30 units of insulin. She then explained, she only verified the amount of insulin not the type and indicated that she should have confirmed the order on the screen with the insulin vial.

During a surveyor interview on 3/15/2023 at 11:54 AM with Employee I, she revealed she forgot the bottle of Lantus Insulin and Employee J went to get it. She stated that Employee J handed her the vial and she "drew up 30 units of the insulin and gave it". She indicated that when she scanned the vial of insulin, she noticed it came up as sliding scale and entered 30 units as the dose to be administered. She further revealed that she noticed the Lantus insulin dose that she just administered was not recorded on the patient's medication administration record. She indicated that she decided to go back and rescan the insulin that was administered and realized that the Admelog Insulin was administered instead of the Lantus Insulin.







45769

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation: Pharmaceutical Services relative to the hospital's failure to prevent a medication error that required additional clinical interventions.

Findings are as follows:

The hospital failed to follow its own policy titled, "Pharmacy Review of the Medication Orders" relative to the appropriateness of the medication, the dose, and frequency, as well as, clarifying concerns, issues, or questions with the prescribing provider prior to dispensing the insulin medication, (Refer A-0500).



45769

Based on record review and staff interview the hospital failed to follow its own policy "Pharmacy Review of Medication Orders" relative to the appropriateness of the medication, dose, and frequency, as well as clarifying concerns, issues, or questions with the prescribing provider prior to dispensing the medication. This resulted in a medication error that required additional clinical interventions for Patient ID #3.

Findings are as follows:

On 3/13/2023, the hospital submitted an incident report to the Rhode Island Department of Health which indicated that on 3/12/2023 Patient ID #3 received 100 units of Insulin Human Lispro, Admelog (a medication used to control blood glucose levels) at 9:28 AM. The report states that at 1:00 PM, a medication error was discovered after Patient ID #3's blood glucose was checked and found to be 26 which necessitated additional clinical interventions other than monitoring.

The following hospital policies were reviewed:

1). The hospital's policy titled, "Medication Administration" last reviewed 2/18/2022 states in part,

"...A. General instructions: CPOE [Computer Physician Order Entry]

1. Physicians or their designees put orders in the computer

2. These medication orders are verified by pharmacy..."

2). The hospital's policy titled, "Pharmacy Review of Medication Orders" dated 4/2021 states in part,

"...Procedure

1. Medication orders are reviewed by a pharmacist for the following:

...c. The appropriateness of the medication, dose, frequency, and route of administration

2. Any concerns, issues, or questions are clarified with the prescriber prior to dispensing of the medication..."

3). The hospital's policy titled, "Medication Orders" dated 4/2021 states in part,

"...Procedure

...When an order is illegible, incomplete or unclear...the prescriber is contacted for clarification...

...Hold Orders

Hold orders are instruction to temporarily suspend an order. A medication placed on Hold is considered discontinued. Unless the physician includes appropriate parameters for resumption..."

4). The hospital's policy titled, "Managing High Alert/High Risk Medications" dated 4/2021 states in part,

...Definitions

...Use with Caution, Heed Alerts Groups: This is a group of medications on the Our Lady of Fatima Hospital High Alert Medications list that require the healthcare professional to utilize caution and address any alerts ..."

Record review revealed that Patient ID #3 presented to the Emergency Department in March of 2023 from a nursing home for a mental health evaluation after becoming combative.

Review of Patient ID #3's "Medication Review Report" dated 3/11/2023 from the nursing home stated that she/he was currently receiving the following:

"Humalog Kwikpen Subcutaneous Solution Pen Injector 100 unit/ml (insulin Lispro) Inject as per sliding scale:

if 200 - 250 = 2 units
251 - 300 = 4 units
301 - 350 = 6 units
351 - 400 = 8 units
401 - 450 = 10 units
451 - 500 = 12 units

Subcutaneously three times a day for dm [Diabetes Mellitus] notify md [Medical Doctor] if <60 or >450."

Record review of "Emergency Department Notes" dated 3/12/2023 at 4:00 AM entered by Employee D, Travel Nurse, stated "Pharmacist called to confirm patient insulin frequency. RN [Registered Nurse] confirmed patient is taking insulin 3x [3 times] daily."

Review of a hospital document titled, "Reconcile Meds" revealed that on 3/12/2023 at 4:55 AM, Employee E, Physician, "converted" the following "reported" medication into an active order:

"Insulin Lispro 100 unit/Ml Insulin. Pen (Humalog Kwikpen)
100 Unit SQ TID
SLIDING SCALE"

This order did not include the insulin administration parameters as they were outlined in the "Medication Review Report" from Patient ID #3's nursing home as stated above.

"Medication Detail ...Insulin Lispro (Humalog Kwikpen) Audit Trail" revealed a "Pending Comment" which stated, "CONSIDER SLIDING SCALE?" This Audit Trail further revealed that this order was cancelled by Employee E, Pharmacist, titled, and re-entered as "Admelog" as follows:

"Admelog 100 UNIT/ML UNIT
Dose 100 UNIT (UNIT 1 ML) ...
...Frequency TID [three times a day] (SCH [scheduled])
Source PHARMACY ORDER CHANGE
Start Date 3/12/23 - 0900 ..."

This report revealed a "Clinical Interventions" detail regarding the order's clarification.

Further review of the Pharmacy's "Clinical Intervention" report revealed a note entered by Employee E, Pharmacist, at 6:48 AM which stated, "RN confirmed insulin lispro dose (100 units TID) based off patient's facility records." This report failed to reveal evidence that the insulin dose was clarified with the ordering prescriber.

Review of the "Medication Administration" record revealed that on 3/12/2023 at 9:28 AM, Patient ID #3 was administered 100 units of Insulin Human Lispro Admelog, subcutaneously by Employee F, RN, and cosigned by Employee G, RN. Additionally, Patient ID #3's "Finger Stick Blood Glucose" level was 222.

Review of the "Fingerstick Blood Glucose" documentation revealed that on 3/12/2023 at 1:16 PM the patient's blood glucose level was 26 milligrams (mg)/deciliter (dL) (normal range 70 - 100).

Further review of the "Fingerstick Blood Glucose" documentation revealed that on 3/12/2023 at 1:25 PM the patient's blood glucose level was 22 mg/dL.

Record review of the "Emergency Department Notes" dated 3/12/2023 at 1:44 PM stated in part that after Employee F identified a low blood glucose level of 26, she notified the physician and administered 4 ounces of orange juice. The note further states that the patient's blood glucose level was rechecked and noted to be 22. Employee F then indicated she administered 50% dextrose (an intravenous medication used to restore blood glucose levels).

Review of the "Emergency Room Visit Notes" dated 3/12/2023 stated in part,

" ...Progress note - [Physician Interim ED Medical Director]

...Notified by nurse that Patient's glucose is 26. Patient chart reviewed. It appears patient received 100 units of insulin this morning ..."

Further review of the "Emergency Room Visit Notes" dated 3/12/2023 stated in part, stated in part,

"Progress note [Employee H, Emergency Department Physician]

...Patient's emergency department course was complicated by patient unfortunately receiving 100 units of subcutaneous insulin this morning, causing [him/her] to become hypoglycemic [low blood glucose] with a glucose of 26 ..."

Additional review of "Emergency Department Notes" dated 3/12/2023 at 2:18 PM stated that the patient's blood glucose level was rechecked and noted to be 89 for which the physician was made aware, and an additional dose of 50% Dextrose was administered to the patient.

During a surveyor interview on 3/15/2023 at 2:11 PM and on 3/16/2023 at 3:45 PM with Employee D, Travel Nurse, he stated that on the early morning of 3/12/2023, a pharmacist called the Emergency Department who asked him how often Patient ID #3 was taking the insulin. He stated that he checked the nursing home rehabilitation paperwork and only confirmed the frequency of insulin, which was to be administered three times daily. He stated that he did not check the patient's hospital medical record and only looked at the nursing home rehabilitation medication list. When asked about the dose of insulin, he stated that he did not look at anything else about the order, other than frequency, since he was not going to administer the insulin, so he did not think about it.

During a surveyor interview on 3/15/2023 at 2:27 PM with Employee E, RN, she stated that she was not told in report by Employee C that the pharmacy had called earlier questioning the insulin order for Patient ID #3. She indicated that the patient's next dose of insulin was due at 1:00 PM and began to think about the dose being too much so she checked the blood glucose level and found it to be 26. When asked if she had any questions about the 100 units of Admelog she administered initially, she stated that she did not, and she did not speak to a physician about it. Additionally, she revealed that the nurse who cosigned insulin administration with her, Employee G, did not question the insulin dose either.

During a surveyor interview on 3/15/2023 at 2:24 PM with Employee E, Pharmacist, he stated that he arrived to his shift at 6:30 AM on 3/12/2023. He revealed that there was an insulin order that was pending from the previous pharmacist for Patient ID #3. He revealed that he saw the patient's medication reconciliation record which stated that the patient was to receive 100 units of insulin, he then stated that he then called the Emergency Department and spoke to a male night nurse who confirmed that the patient was receiving 100 units of insulin three times a day. He stated that he communicated to the nurse that this dose was a very high dose and the nurse then read verbatim "100 units TID." He was told by the male night nurse that he would look into it further but did not mention he would speak to the physician. He stated that typically when the Emergency Department is called to clarify orders, the physician is on the line. He stated that he did not hear back from nursing until the incident occurred. He stated that his intention after re-entering the insulin order as Admelog, was to place a hold on the medication which he failed to do. This would have prompted staff to "look into it."

During a surveyor interview on 3/15/2023 at 1:40 PM with the Pharmacy Manager she stated that Employee E should have placed the medication on hold which would have prevented the nurses from administering the medication. Additionally, she stated that the expectation is that the pharmacist speaks to the ordering provider, but the nurse can facilitate this process.

During a surveyor interview on 3/16/2023 at 11:14 AM the Clinical Informatics Pharmacist and the Pharmacy Manager, the Clinical Informatic Pharmacist stated that the sliding scale parameters should be listed, and that the physician did not enter the order correctly initially. He stated that the "hold" function on the insulin order would have prevented the administration of insulin.




45769