HospitalInspections.org

Based on record review, policy 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 a standard of practice for use of an insulin syringe and failure to follow the hospital's policy related to medication administration resulting in a patient being given an incorrect insulin dose, resulting in a clinical intervention other than monitoring for Patient ID #1.

1. The hospital failed to provide nursing care in accordance with the hospital policy for, "Insulin Administration Subcutaneous" (refer to A-405)

Based on policy review, record review and staff interview, it has been determined that the hospital failed to administer medications in accordance with hospital policy for 1 of 3 patients reviewed who received insulin, Patient ID #1.

Findings are as follows:

A report submitted by the hospital on 10/18/2023 revealed that Patient ID #1 received the wrong dose of insulin, causing hypoglycemia (low blood sugar), after it was administered using an incorrect syringe.

The following hospital policies were reviewed:

A. The hospital's policy titled, "Insulin Administration Subcutaneous" dated 6/2023 states in part,

"...Medication Administration Procedure...

c. Verify provider order against the medication administration record...

d. Draw up insulin with a second nurse/witness to verify the appropriate dose..."

5. The two nurses involved in preparing the insulin complete the verification process utilizing 2 patient identifiers..."

B. The hospital's policy titled, "High Alert Medications" dated 11/2022 states in part,

"Policy...

High alert medications are identified, and action is taken to proactively promote safe procurement, storage...administering and monitoring of the high alert medications and/or minimize the occurrence of an error.

...Definitions

High-Alert Medications: medications involved in a high percentage of errors, as well as medications that carry a higher risk...

...Safety Strategies:

...Insulin: Abbreviations of units is prohibited, second RN witness for insulin administration..."

Record review revealed Patient ID #1 who is 37 weeks pregnant presented to the hospital on 10/10/2023 for hyperglycemia requiring inpatient glucose monitoring. The Patient has a past medical history that includes poorly controlled type one diabetes.

Record review revealed a physician's order dated 10/15/2023, for Insulin Lispro to be administered via Carbohydrate Ratio as follows:
Meals: Give one unit of insulin for each 5 grams of carbohydrate
***USE this for insulin given with MEALS***

Record review revealed a medication administration record dated 10/16/2023 documenting that the patient was administered 11 units of Lispro Insulin at 8:00AM by Registered Nurse, Employee A, and was witnessed by Registered Nurse Employee B.

Further record review revealed a physician "Acute Event Note" dated 10/16/2023 at 1:42 PM revealing the following:
MD was notified patient was hypoglycemic (low blood sugar). Per RN "patient had 55 grams of carbohydrates with breakfast, patient ordered for 1 unit of lispro per 5 grams of carbohydrates. Patient received 110 units of Lispro Insulin at 8:30 AM. Patient received 10 times the insulin dose that was indicated per carbohydrate ratio."

Review of the patient's Blood Glucose levels revealed the following results:
10/16/23 at 11:30 AM BG (blood glucose) 53
documentation of testing reason: patient symptomatic
10/16/23 at 12:25 PM BG 53
documentation of testing reason: patient symptomatic
10/16/23 at 1:15 PM BG 59
10/16/23 at 1:50 PM BG 62

During a surveyor interview on 10/19/2023 at 2:40 PM with Employee A, she indicated that on 10/16/2023, she administered Patient ID #1's morning insulin and calculated the patient was to receive 11 units of Lispro insulin. She entered the patient's room with Employee B and verified the patient and date of birth and then drew up the insulin that was to be administered. She then gave the insulin syringe to Staff B to verify the dosage and then administered the insulin to the patient. Staff A then stated around 11:30 AM the patient reported to her that she had a blood glucose level of 53 per her self-glucose monitor. After following the hypoglycemic protocol, the patient continued to have a blood glucose of 53 and she notified the physician the patient was symptomatic and hypoglycemic. Staff A, then disclosed that she realized that she had drawn up the morning dose of insulin in the wrong syringe after seeing another nurse gather an orange tip insulin syringe and notified the physician of the error. She acknowledged that she used a 1 cc syringe instead of the insulin 100 unit syringe and that she did not notice that the syringe did not have unit markings.

During a surveyor interview on 10/19/2023 at 2:55PM with Employee B, she stated that she entered the patient's room to verify the insulin dose on 10/16/2023 around 8:30AM. She revealed that the insulin was already drawn up in the syringe and she verified the dose as being 11 units of Lispro insulin. The type of insulin was confirmed along with the patient's identity, and the insulin was administered by Employee A. Staff B, acknowledged that she did not realize that the insulin was drawn up with the wrong syringe when she did the double check to verify the correct dosage is administered. She also did not notice that the syringe did not have the unit markings which are specific to an insulin syringe.

During a surveyor interview with the attending physician on 10/23/2023 at 9:53 AM, he revealed that he was made aware of the insulin error that occurred on 10/16/2023. He stated that the patient required a peripheral intravenous line and administration of 10% Dextrose with frequent blood glucose checks.

During a surveyor interview with the Clinical Effective Manager on 10/19/2023 at 9:30 AM, she acknowledged that the insulin was not administered using the correct syringe, causing the patient to receive an excessive dosage of Lispro insulin.