HospitalInspections.org

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the nursing staff failed to administer patient medication, as the physician(s) ordered and intended for 1 of 4 patients (Patient #1).

Findings include:

A review of the "Sliding Scale Subcutaneous (SQ) Insulin Order Set" revealed the monitoring of blood glucose as follows: "...Obtain blood glucose finger stick 30 minutes before meals and at bedtime or every 4 hours when NPO (nothing per mouth). Obtain additional blood finger stick at 0300, if rapid-acting insulin aspart (Novolog) given at bedtime. Obtain additional blood finger stick as needed for signs of hypoglycemia...."

Review of Physician #1's Orders for Patient #1 revealed admission orders for Sliding Scale Subcutaneous Insulin.

The provider's investigation revealed: the pharmacist (employee #3) reviewed the medical record and was unable to confirm documentation of insulin administration for 1/30/10 at 0730, and 1/30/10 at 1130, both of which appear to have been when the patient was still in the Emergency room.

This surveyor was unable to locate documentation of blood sugar results before meals or the administration of insulin on 1/30/10 before 1700.