HospitalInspections.org

482.13 Tag A-0115

The information reviewed during the survey provided evidence the facility failed to ensure a patient on a continuous insulin infusion was getting Accuchecks every hour (blood glucose monitoring), as required per hospital policy.

A discussion took place with the survey team and the facility's administrative staff (EMP1), regarding the survey team's concerns related to Patient's Rights on January 12, 2021 at 4:44 PM.


Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on review of policies and procedures, facility documents, and medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow its own established policy by failing to ensure blood glucose point of care checks were performed on an hourly basis for a patient who was on an Intravenous Insulin drip in one of one medical records reviewed (MR1).

Findings include:

Review on January 12, 2021, of facility document, dated November 24, 2020, revealed "Patient triaged in ED [emergency department] on 11/23/20 @ 10:04 with report of two syncopal episodes at home; History of IDDM [insulin dependent diabetes mellitus] and STEMI [ST-elevation myocardial infarction]; Initial serum glucose 369 mg/dl; Patient admitted for treatment of DKA [diabetic ketoacidosis] and AKI [acute kidney injury]; Received NaCl [sodium chloride] IV [intravenous] infusion for hydration and Humalog IV protocol prescribed ... glucose measurements should have been taken Q1H [every hour] upon initiating the Insulin but no POC [point of care] glucose measurements done until a BMP [basic metabolic panel] specimen was sent @ 17:43; Critical result of Glucose 40 mg/dl called to RN [registered nurse] @ 18:37; RN approached oncoming night-shift RN to report patient had been alert & oriented but suddenly became unresponsive; Insulin infusion was stopped and POC glucose checked which was resulted as <12 mg/dl; ..."

Review on January 12, 2021, of the facility's policy "Patient Rights and Responsibilities", dated March 26, 2020, revealed "You have the right to respectful care given by competent personnel, which reflects consideration of your personal rights ... You have the right to good quality care and high professional standards that are continually maintained and reviewed. "

Review on January 12, 2021, of the facility's "Protocol: Continuous Insulin Infusion for Hyperglycemia, revised April 2012" revealed, "If blood glucose is greater than 300 mg/dl. Accucheck every 1 hour."

Review of MR1 on January 12, 2021, revealed this patient did not receive bedside glucose monitoring checks on November 23, 2020 from 10:45 AM until 7:08 PM of the same day. An order for "HumaLOG 100 unit/100 ml (IVPG) [intravenous piggyback] see paper protocol" was ordered on November 23, 2020 at 12:15 pm. At 6:30 PM, Nurse (RN) received low BS [blood sugar] <12 mg/dl, RN stopped insulin, ... patient awake and talking, 6:55 PM, RN assessing patient, patient in and out of sleep talking, 7:10 PM, rapid response called.

Interview with EMP1 on January 12, 2021, at 11:02 AM, confirmed EMP3 did not follow the appropriate physician orders for "HumaLOG 100 unit/100 ml (IVPG) [intravenous piggyback], ..." and facility policies and procedures related to continuous insulin infusion for hyperglycemia. EMP1 also confirmed there was no documented evidence that the patient's insulin levels were checked for approximately seven hours while on the insulin drip. EMP1 also confirmed that EMP3 was on leave and unavailable for an interview.

Interview with EMP2 on January 13, 2021 at 11:30 AM, confirmed EMP3 did not follow the appropriate physician orders for "HumaLOG 100 unit/100 ml (IVPG) [intravenous piggyback], ..." and facility policies and procedures related to continuous insulin infusion for hyperglycemia. EMP2 also confirmed there was no documented evidence that the patient's insulin levels were checked for approximately seven hours while on the insulin drip.