HospitalInspections.org

Based on interview and document review the facility failed to insure 1 of 5 patients (P1) received discharge evaluation to insure continued administration for new ordered daily insulin and blood glucose monitoring following discharge from acute care to an independent living situation.

Findings include:

Review of P1's medical record revealed he was admitted to the hospital on 6/8/21, as a transfer from another hospital emergency department, (ED) where he had presented due to a persistent rash, he had diagnoses that included traumatic brain injury, (TBI), hypertension, type 2 diabetes (previously diet controlled), legal blindness, obstructive jaundice (a yellowing of the skin and the whites of the eyes). P1 was started on continuous insulin infusion for hyperglycemia, (high blood sugar) because his blood sugar was 469 (normal blood glucose range 70-100).

Following admission to the hospital a gastrointestinal assessment was performed on 6/9/21, and revealed a pancreatic mass. P1 was transitioned to Lantus (long acting insulin) and then transitioned to Lantus 20 units subcutaneous (SQ) every (q) morning (am) to be continued following discharge (d/c). In addition P1 had provider orders for blood sugars (BS) to be checked twice daily, before he ate or drank in the morning and before dinner. The hospice team was consulted and P1 was to discharge home with hospice services who were scheduled to meet him at his apartment following hospital discharge on 6/13/2021.

During interview with hospice registered nurse (RN)-H on 6/24/21, at 2:00 p.m., she indicated she had arrived at P1's apartment on 6/13/21, at 1:00 p.m., for the admission to hospice services. RN-H defined hospice service as an intermittent nursing service that provided education and support but, clarified, did not provide administration of insulin or other medications. P1, and family members (FM)-A (P1's power of attorney for healthcare) along with her spouse were in attendance for the admission process. Due to his physical and mental limitations, P1 was not able to check his own BS or administer insulin to himself. FM-A and her spouse confirmed to RN-H there had not been any discussion prior to P1's discharge other than he would have an order for insulin and BS checks, and hospice would come to the home to admit P1 to hospice. FM-A along with her spouse stated they had not been asked by hospital staff if they would administer insulin and/or check BS and did not receive any education about the insulin or BS. Supplies provided from the hospital pharmacy included oral medications, Lantus insulin pen and needles but there was not a blood glucose meter, nor a provider script to obtain one. When RN-H questioned about insulin administration in the hospital FM-A replied the nurse had come into the room and administered P1's insulin and checked BS, but nothing had been communicated about administration of P1's insulin other than hospice would assist them. RN-H indicated following the meeting with P1 and his family she immediately contacted the hospice medical director who gave the order to hold P1's insulin until arrangements could be made for transition to a higher level of care. RN-H updated the hospice supervisor, the unit RN-E from the hospital, and the hospital social worker (LSW)- C of the situation with P1's discharge plan.

Interview with RN-E, on 6/24/21, at 9:00 a.m., indicated the facility's diabetes education department normally provided teaching on administration of insulin and/or checking of blood glucose, but on weekends or after hours, the nursing staff were responsible to provide the education. The LSW scheduled on the unit had the responsibility to update unit staff on the planned discharge, coordination of community resources and insure the patient had resources arranged to provide the care and services needed following discharge. RN-E identified a patient would not be discharged until a safe situation was in place to provide the care and services indicated in their plan of care. In addition the unit had a printed procedure, "Standard Work for Planned Morning Discharge Patients" that detailed tasks to be completed that started 24 hours before the planned date of discharge. RN-E indicated when P1 was discharged it was assumed hospice services would manage his insulin and BS, but no verification had taken place to confirm the service, nor was there documentation to confirmed the discharge process had been followed for the 24 hours prior to the discharge.

Interview with RN-I, a patient care liaison, on 6/24/21, at 9:45 a.m., indicated she had received a complaint regarding P1 on 6/14/21, related to the lack of coordination of care for home insulin administration and blood glucose checks. RN-I stated she had forwarded the concern to LSW-C who responded that hospice would take over the insulin administration.

Interview with FM-A on 6/24/21, at 9:52 a.m., stated P1 had been discharged on 6/13/21, with a discharge form which listed his medication to include Lantus insulin to be administered Q am and BS checks twice daily. FM-A stated she had been told hospice would provide education and answer questions as needed and she had assumed this included the administration of insulin and BS checks. FM-A stated she was not asked nor did she receive any education related to the administration of insulin or checking BS, which she was not willing to do. Following the hospice nurse home visit, arrangements were initiated for transfer of P1 to a higher level of care facility for medication and BS management.

Interview with nurse practioner, who also managed the diabetic education department, on 6/25/21, at 9:36 a.m., indicated there was some of the confusion about P1's discharge that had occurred as a result of the endocrinologist who recommended a transitional care unit or skilled nursing facility, which had been declined by both P1 and the family. She stated that following review of P1's medical record it was determined P1 would not have been able to self administer insulin or check his own BS. She stated it should have been identified, prior to P1's discharge, that he would require someone to manage his insulin administration and BS checks and discharge delayed with a consultation requested from diabetic education to aide in development of an acceptable plan prior to his discharge.

Interview with LSW-B on 6/25/21, at 5:30 p.m. identified she had been the LSW on the unit on 6/12/21, and had no communication with P1, only with FM-A. She indicated the topic of conversation was directed toward the provision of transportation home, the provision of diabetic focused meal planning, and the decision to initiate hospice services. LSW-B stated she had communicated hospice would be available to provide education and guidance, but there was no discussion on administration of insulin or checking BS. LSW-B stated she had communicated with hospice via care navigation's and had updated the unidentified contact that P1's family member was uncomfortable and would need support and guidance.

Review of the document, Standard Work for Planned Morning Discharge Patients (undated) included tasks to be completed beginning on the day shift on the day before discharge and continuing each shift until the morning when the patient was to be discharged from the facility. The day shift before discharge included, assess and order any needed equipment. Communicate discharge plans during the bedside shift report with to do list including what is needed for patient to discharge the next day. Evening shift before discharge included, reinforce discharge teaching, check for needed equipment and order as needed, communication with shift report to do list and any follow up needed. The night shift before discharge included reinforce education as able, communicate discharge plans during bedside report, include any outstanding needs, follow up for equipment needed and discharge preparation status. Day of discharge included determine if patient still meets criteria for discharge, confirm if family will be present for discharge instructions, review of discharge orders and gather needed equipment/supplies/medications.