HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the screen of the computer for one current patient (#23) of two insulin administrations observed. (A-0405)
- Ensure insulin prepared from a multi-dose vial was properly labeled for two current patient (#13 and #23) of two insulin administrations observed. (A-0405)
- Safely secure medications when the medications were left unattended on top of a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) in a patient room for one current patient (#16) of seven medication administrations observed. (A-0405)
- Properly administer medications when they documented the medications prior to giving them to three current patients (#13, #14, #15) of seven medication administrations observed. (A-0405)

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 05/07/25, the hospital provided immediate action plans sufficient to remove the IJ when the hospital implemented corrective actions that included insulin administration education to all nursing staff who were qualified to administer medications.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services.

Please refer to A-0405.

Based on observation, interview, record review and policy review, the hospital failed to:
- Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar code label on the screen of the computer for one current patients (#23) of two insulin medication administrations observed.
- Ensure insulin prepared from a multi-dose vial was properly labeled for two current patients (#13 and #23) of two insulin administrations observed.
- Safely secure medications when the medications were left unattended on top of a workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) in a patient room for one current patient (#13) of seven medication administrations observed.
- Properly administer medications when they documented the medications prior to giving them to three current patients (#13, #14 and #15) of seven medication administrations observed.

Findings included:
Review of hospital policy titled, "Medication Administration Nursing," revised on 01/30/25, showed:
- Medications should be returned to the medication room if they are not administered.
- Medications should not be administered if they are not properly labeled.
- During the administration of medications, the patient's identification band is scanned and along with the medication package.
- Record in the patient's record the time of any medication administration.

Observation on 05/06/25 at 9:00 AM, Staff AA, RN, withdrew two units of insulin in a syringe from a multi-dose vial. She did not label the syringe and was walking towards Patient #13's room when Staff # O, Educator, stopped Staff AA and told her she needed to put a label on the syringe.

During concurrent observation and interview on 05/06/25 at 12:30 PM, with Staff T, RN, showed Staff T, RN, standing outside of Patient #23's room with an unlabeled syringe sitting on top of the WOW. Staff T indicated the syringe contained insulin and she had a bar code label attached to the computer that she used for scanning insulin.

During an interview on 05/06/25 at 12:35 PM, Staff Q, Director, stated she was aware that staff used barcode labels attached to their computers for scanning insulin. The expectation per policy was to label each individual syringe with the appropriate insulin barcode that would be scanned at the bedside when the insulin was administered.

During an interview on 05/06/25 at 1:30 PM, Staff D, Chief Nursing Officer (CNO), stated that nurses should label all insulin syringes with the corresponding barcode. Barcode labels should not be attached to the computers for repeated scanning when administering insulin to multiple patients.

Observation on 05/06/25 at 8:40 AM, showed Staff N, RN, preparing to administer medications to Patient #13. Applesauce was required for Patient #13's medications. Staff N left Patient #13's medications unattended on top of the WOW in Patient 13's room when she exited the room to obtain the applesauce.

Observation on 05/06/25 at 9:00 AM, showed Staff N, RN, documented the administration of medications prior to administering them to Patient #13.

Observation on 05/06/25 at 9:15 AM, showed Staff N, RN, documented the administration of medications prior to administering them to Patient #14.

Observation on 05/06/25 at 9:55 AM, showed Staff N, RN, documented the administration of medications prior to administering them to Patient #15.

During an interview on 05/06/25 at 1:30 PM, Staff D, CNO, stated nurses should not document a medication was given prior to actually administering the medication to the patient. Nursing staff should not leave medications unattended at any time.