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Based on staff interview and clinical record review, it was determined that the facility nurse failed to follow facility policy to ensure accurate documentation of the discharge summary for one (#1) of three records reviewed. This practice may cause a delay in care or necessary use of medical services to obtain care for potential adverse outcomes.

Findings include:

A closed chart review of patient #1 revealed the patient was admitted on 3/12/2010 and had a diagnosis of intra-abdominal hematoma, COPD, CHF, diabetes and T-11 fracture. On 3/29/10, the physician progress notes revealed discharge medication orders which listed Lantus 10 units subcutaneous (sq) every hour of sleep (hs). The discharge medication reconciliation form revealed the discharge medications written by the physician on 3/29/2010 which listed Lantus 10 units sq every hs. The nursing discharge summary (NURS00054P-01), dated 3/30/2010, revealed the discharge medications and treatments for patient #1. The form was dated and signed by the patient's caregiver and the nurse. The first medication listed was Lantus 100 units sq every hs.

An interview with a staff nurse on unit at 11:45 a.m. on 4/21/10 revealed that the nurses role in the discharge process included input during the every am lightning rounds about potential discharges and issues, assistance in preparing the patient and family for impending discharges, reviewing discharge instructions with family and patient, social service copies the chart for transfers and sets transportation for patient. The nurse would prepare the medication discharge instructions according to physician's discharge orders that they wish to have patient continue upon transfer. Discharge instructions and medication lists are reviewed and signed by the family and/or patient and placed in a transfer envelope for transport. An interview with the Director of Patient Safety and Director of Discharge Planning at 2:15 p.m. on 4/21/10, confirmed that the nursing discharge summary revealed Lantus 100 units sq every hs. They also confirmed that the physician progress notes and the physician medication reconciliation form revealed Lantus 10 units sq every hs. A review of patient #1's Medication Administration Record revealed Lantus 10 units sq every hs at 10:00 p.m. They both stated that there was a transcription problem. Patient #1's nurse completed the discharge summary for patient #1 and had access to the clinical record. This nurse was not on duty today on the day of the survey. The Director of Discharge planning stated that the Medication Reconciliation Form, the physician discharge orders, and the nursing discharge summary were sent to a skilled nursing facility along with the CMS 3008. The clinical record was reviewed by the Director of Patient Safety. The clinical record only had page 2 of the CMS 3008. S/he stated that the form may not have been scanned into the system.

A review of the facility policy and procedure, #2.00.006.5 for Patient Discharge, page 2, revealed under documentation that the registered nurse assures that the Discharge Summary Form (NURS00054-P-01) is completed accurately and reviewed with the patient/family.

The hospitalist for patient #1 was interviewed at 10:25 a.m. on 4/22/2010 who confirmed the writing of Lantus 10 units sq every hs on the progress notes and on the medication reconciliation form. The nursing discharge summary that listed Lantus 100 units sq every hs was transcribed incorrectly. The hospitalist stated that in his/her experience that she has seen Lantus in large doses. She stated that with the administration of this, dose one would expect adverse outcomes. This medication is a long acting insulin and delivers a steady level for 24 hrs commonly used at bedtime.

Patient #1 was discharged to a nursing facility on 3/30/10. The patient was returned to the Emergency Room (ER) on 3/31/10 at 11:10 a.m. The transfer and referral record revealed the reason for transfer was listed as respiratory distress with comments, a blood sugar at 8:15 a.m. was 29, given glucagon injection, oxygen saturation 79%, oxygen mask placed on, oxygen saturation up to 93%, but when reduced oxygen the saturation decreased. Dextrose 5% intravenous (IV) was started at a rate of 60cc/hr. The ER physician report revealed initial diagnostic impression: hypoglycemia was now resolved and decreased oxygen saturation. Patient #1 was admitted for further care. The ER record also included the skilled nursing facility's physician order record, dated 3/30/10, which revealed Lantus Subcutaneous Solution 100unit/ml- 100 units sq bedtime 9:00 p.m. and was given last night.

5/15/2010