HospitalInspections.org

Based on interview and record review it was determined the hospital did not ensure medications, specifically insulin, was given in accordance with written and signed orders. Patient identifiers: 5 and 23.

Findings include:

1. Patient 5 was admitted to the hospital on 7/23/17, with diagnoses of Diabetic Ketoacidosis (DKA) and Diabetes Mellitus (DM), type 1.

A review of patient 5's medical record was completed on 7/27/17.

A physician's order dated 7/23/17 revealed the following: Humalog (a type of insulin) carbohydrate to insulin ratio, give 1 unit for every 5 grams of carbohydrate consumed with meals and snacks.

Patient 5's meal and snack intake during his hospital stay, 7/23/17 to 7/25/17, was reviewed. Hospital staff documented patient 5 consumed seven meals and/or snacks.

Patient 5's Medication Administration Record (MAR) showed he received four doses of Humalog per the carbohydrate to insulin ratio order during his hospital stay.

Note: Patient 5 should have received 7 doses of Humalog per the carbohydrate to insulin ratio order to correlate with his meals and/or snacks consumed.

Patient 5's Discharge Summary dated 7/25/17 by physician 1 revealed, "...His blood sugars weren't great. There was also an error where nursing wasn't giving him insulin to correct for his carbs..."

On 7/25/17 at 3:40 PM, an interview was conducted with the hospital Risk Manager (RM). The RM confirmed patient 5 did not receive all ordered doses of Humalog per the carbohydrate to insulin ratio. The RM further stated that physician 1 did not report the error as he should have.

2. Patient 23 was admitted to the hospital on 2/12/17 with a diagnosis of type 2 DM with hyperglycemia (high blood sugar).

A review of patient 23's medical record was completed on 7/27/17.

A physician's order dated 2/12/17 at 9:36 PM revealed the following: Humalog correction factor scale 1 to 9 units every 4 hours as needed for hyperglycemia. The scale was listed as follows: if blood sugar (BS) 141-170 mg/dL (milligrams per deciliter) give 1 unit, 171-200 mg/dL give 2 units, 201-230 mg/dL give 3 units, 231 to 260 mg/dL give 4 units, 261-290 mg/dL give 5 units, 291-320 mg/dL give 6 units, 321-350 mg/dL give 7 units, 351- 280 mg/dL give 8 units, 381-400 mg/dL give 9 units, and greater than 400 call provider.

Patient 23's blood sugars were reviewed from 2/12/17 at 9:36 PM, the time the Humalog correction factor scale order was placed and 2/13/17 at 8:01 AM, the time the first dose of Humalog insulin per the correction factor scale was given and the following values were listed:

a. On 2/12/17 at 10:56 PM, 354 mg/dL

b. On 2/13/17 at 6:43 AM, 277 mg/dL

c. On 2/13/17 at 7:15 AM, 318 mg/dL

Patient 23's Medication Administration Record (MAR) revealed that on 2/13/17 at 8:01 AM, he received 5 units of Humalog insulin per the correction factor scale for a BS of 277 mg/dL.

Note: Patient 23 should have received 8 units of Humalog insulin per the correction factor scale on 2/12/17 at 10:56 PM and did not. Also per patient 23's MAR the 5 units of Humalog insulin for his BS of 277 mg/dL was not administered until one hour and 18 minutes after the BS was noted and after an increased BS of 318 mg/dL was found at 7:15 AM.