HospitalInspections.org

Based on observations, interview and facility policy review, the facility failed to prepare and administer insulin during Medication Pass according to their written policy and procedures for insulin administration for 2 (#1,
#14) of 3 patients whose medication administration was observed.


The findings include:


1. An observation of the medication pass of Employee A was conducted on 07/08/2015 at 12:03pm, at which time Employee A was observed holding an alcohol packet which had various numbers written on it. Employee A responded to the surveyor that she was preparing to administer insulin to Patient #14. This surveyor observed the Medication Pass with the facility Risk Manager while preparing the medication dose for Patient #14. Employee B was present in the medication room while Employee A told Employee B; verifying the insulin withdrawn from the vial (Insulin Aspart, NovoLog) reached up to the 9 unit measurement (confirmed by observation by this surveyor, again with the Risk Manager present). Employee B stated, "Yep, 9 units".

Employee A returned the vial into the medication dispense machine and exited the medication room with this surveyor introduced to the patient at 12:07pm.

Employee A then explained the procedure to Patient #14, at which time he selected to have the insulin injected into his Left Lower Abdomen after routine cleansing of the site, and then Employee A returned to the computer to document the administration of the 9 units. This surveyor then requested a review of the information used to base the retrieval of the insulin administration and Employee A demonstrated where she would look at the blood glucose level in the computer stating, "If it is there"; she entered a field that reflected a current bedside glucose level of 319 milligrams per deciliter. She was then asked by this surveyor to demonstrate how to retrieve the information that guides her on how much insulin to administer. She entered a field that reflected the Protocol Text, Insulin Aspart and (BG) Blood glucose Level Instructions, which include the following two of many entries:

251-300 Give 9 Units (SC), subcutaneously.
301-350 Give 12 Units (SC) subcutaneously And call the physician

Employee A was then asked, what dose she administered, and Employee A responded, "9 units; I guess I have to give 3 more." This surveyor then requested that Employee A confirm the policy and procedures with Employee B and ensure that the information is correct. A review of the facility's policy "Medication Administration General Rules" was conducted, and documents on page 2 of 5 section/item number 13: All, insulin, Heparin and pediatric (Under age of 17) drugs will be double-checked by a second licensed person for accuracy of dose, according to order before administration and documented in the Pyxis and/or co-signature on the Electronic Medication Administration Record (EMAR). (Insulin is ordered by the physician and the sliding scale is ordered by the physician as a hospital protocol; this requires the nurse to access the valid glucose reading for which the insulin selected for administration is to be administered for coverage).

2. Record review revealed that Patient #1 was admitted on 7/5/15 with diagnoses of headache and increased blood sugars. Interview on 7/8/15 at 12:00pm with Employee C, Registered Nurse (RN), revealed that Patient #1's blood sugar on 7/8/15 at 11:00am was 338 (high). Employee C had an insulin syringe in her hand that contained a clear fluid. Employee C stated that the clear fluid was 15 units of NovoLog insulin (fast acting) for Patient #1. Employee C stated that Patient #1 was prescribed 3 units of regularly scheduled NovoLog insulin, plus 12 units of NovoLog insulin per sliding scale for the patient's blood sugar of 338, a total of 15 units of insulin. Employee C then looked up Patient #1's Medication Administration Record (MAR) at the bedside medication verification work station, and stated that Patient #1's scheduled NovoLog insulin was increased to 8 units that morning. Employee C said she would waste the insulin she had already drawn up for the patient, and "start fresh." Employee C then walked to the Medication Room, and asked Employee D, RN, to accompany her. After debating whether to add more insulin to the dose already drawn up, or waste that dose and draw up the correct amount, Employee C wasted the previously drawn insulin into the sink, with Employee D as a witness. Employee C removed a multi-dose vial of NovoLog insulin from the automated medication dispensing machine drug storage system, and drew up a new dose of insulin for Patient #1. The Chief Nursing Officer (CNO) and the Charge Nurse were also in the Medication Room as Employee C drew up the new dose of insulin and repeatedly said out loud, "Eight plus 12 is 21. Eight plus 12 is 21." None of the nurses in the room corrected Employee C's calculation. While Employee C drew up the new dose of insulin, Employee D had her back to Employee C and looked at a work station computer screen. Employee E did not look at the insulin that Employee C drew up to verify the correct dose. This surveyor observed the insulin dose that Employee C drew up for Patient #1. The syringe contained 22 units of insulin.

Employee C took her bedside work station to the doorway of Patient #1's room, and donned Personal Protection Equipment (the patient was on contact isolation precautions). Employee C checked the patient's dose of insulin on the electronic MAR again. Employee C scanned the patient's identification bracelet, and scanned the label on the syringe of insulin. Employee C turned and began to approach the patient with the syringe of insulin in her hand. The surveyor asked Employee C if she was ready to administer the insulin to Patient #1, and Employee C answered "Yes." The surveyor asked the CNO to verify how much insulin was in the syringe. The CNO examined the syringe and said, "21 units." The surveyor then told Employee C to remove her PPE, and go to the Medication Room. The surveyor also asked Employee D to come to the Medication Room. The CNO and Employee C met in the hallway on the way to the Medication Room, and talked briefly. Employee C then said that the dose of insulin for Patient #1 should be 20 units. In the Medication Room, the surveyor asked Employee D how much insulin was in the syringe. She said, "21 units." The Charge Nurse entered the room, and the surveyor asked him how much insulin was in the syringe. He examined the syringe and said, "21 units." The surveyor observed the syringe of insulin again, and said it contained 22 units of insulin. The Charge Nurse checked the syringe of insulin again and said, "It's a little over 21, not quite 22 units." The surveyor asked Employee D what the process was for verifying the insulin dose for another nurse. She said she checks the dose on the resident's order. Employee C said, "I think you're supposed to check the dose in the syringe." Employee D said, "The other nurse was here, so I didn't check it."

Review of physician's orders for Patient #1 revealed a start date of 7/7/15 at 4:55pm for 3 units of NovoLog insulin, with a stop date of 7/8/15 at 11:12am. The label stated, "This is a high alert medication; please double-check patient, med, sig, and strength prior to administration." Review of the patient's MAR revealed an order dated 7/8/15 at 11:55am for NovoLog insulin 8 units, 5 minutes before meals. Review of sliding scale insulin orders for Patient #1 revealed for a blood sugar from 301-350, give 12 units of NovoLog insulin.

Review of the facility's policy titled "Medication Administration General Rules," last review date 7/2013, revealed that the "Rights" in the administration of medications include the right dose. All insulin will be double-checked by a second licensed person for accuracy of dose according to order before administration. Always check and recheck calculations in preparing medication or adjusting a dose. Have a second nurse check the calculations.