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Based on interview, record review and review of the facility's policies, it was determined the facility failed to ensure drugs were administered in accordance with the orders of the practitioner responsible for the patient's care and accepted standards of practice for one (1) of ten (10) sampled patients (Patient #1).

Patient #1 had Physician's Orders for Sliding Scale Insulin (SSI); however, record review of the Medication Administration Record (MAR) and interview with staff revealed the incorrect dosage of SSI was administered on several occasions in 09/12.

The findings include:

Review of the facility policy titled, "Blood Glucose Monitoring Using Fingerstick", revised August 2010, revealed blood glucose levels will not be used for definitive diagnosis but will be obtained from the patient when ordered by the Physician in an accurate and safe manner to the patient.

Review of the facility policy titled, "Insulin Administration", revised January 2007, revealed the policy was to maximize patient safety by assuring the accurate administration of Insulin. The policy stated staff was to double check the dose in the syringe with another nurse and both nurses were to initial the MAR.

Review of Patient #1's medical record revealed the patient was admitted to the facility on 09/05/12 with diagnoses which included Mood Disorder and Type I Diabetes.

Review of the Master Treatment Plan, dated 09/05/12, revealed the patient was Insulin dependent, received Lantus Insulin sliding scale, and his/her blood sugars were up and down. The goal stated the patient's blood sugar would remain within normal range. The interventions included performing finger stick blood sugars, administering routine insulin, and administering sliding scale insulin.

Review of the Physician's Orders, dated 09/06/12, revealed orders for Lantus Insulin thirty-two (32) Units subcutaneous (SQ) at hs (night), accuchecks before meals and at hs, SSI Novolog one (1) unit for every ten (10) carbs after meals, SSI Novolog one (1) unit for every fifty (50) above 150 Blood Sugar (BS) after meals at 8:30 PM, 12:30 PM, and 5:30 PM.

Review of the Medication Administration Record (MAR), dated September 2012, revealed there was a box on the MAR to document how much Novolog SSI was administered per the accucheck and a seperate box to indicate how much Novlog SSI was administered as per the carb count. Continued review revealed on 09/07/12 Patient #1's accucheck at 11:30 AM was 428. However, according to the MAR only three (3) units of Novolog SSI was administered as opposed to five (5) units per calculation of Physician's Orders. In addition, Patient #1 received Novolog Sliding Scale eight (8) units per the carb count; however, there was no documented evidence of what the carbs were for the noon meal.

Further review of the 09/12 MAR revealed on 09/08/12 at 7:30 AM Patient #1's accucheck was 179. According to the MAR the patient received one (1) unit of Novolog SSI at 8:30 AM, even though the BS was not fifty (50) above 150 as per orders.

Review of Physician's Orders dated 09/11/12 revealed new orders to discontinue the previous sliding scale of one (1) unit per every 50 over BS 150, Novolog, and start sliding scale Novolog with meals three (3) times a day (tid): BS 150-200 give 2 units, BS 201-250 give 4 units, BS 251-300 give 6 units, BS 301-350 give 8 units, BS 351-400 give 10 units, BS 401-450 give 12 units, BS 451-500 give 14 units, BS 501-550 give 16 units, and BS 551 plus, call Physician.

Review of the MAR, dated 09/12 revealed on 09/14/12 at 11:30 AM Patient #1's accucheck was 279 and at 12:30 PM the patient received nine (9) units of Novolog SSI as opposed to seven (7) units as per Physician's orders.

Continued review of Physician's Orders revealed orders on 09/16/12 to cancel all previous Insulin Orders and start Lantus 26 units every night (hs), Novolog SSI one (1) unit for every twelve (12) carbs, Novolog SSI one (1) unit for every 50 above 150 BS after meals, staff to monitor food intake/carb count.

Review of the MARs revealed Patient #1's accucheck was being checked before meals and at night and after meals and recorded on the MAR. Review of the accucheck, for 09/18/12 at 7:30 AM, before meals was 154 and accucheck after meals at 8:30 AM was 311. According to the MAR, four (4) units of Novolog SSI was administered as opposed to three (3) units per calculation of MD orders. (The patient also received an additional 3 units of Novolog SSI for the carb count, although there was no documented evidence of what the carb count was for the breakfast meal). In addition, Patient #1's accucheck on 9/18/12 at 11:30 AM was 233 and accucheck at 12:30 PM was 312. According to the MAR, four (4) units of SSI was administered as opposed to three (3) units per calculation of Physician's Orders. In addition, the patient also received 5 units of Novolog SSI per the carb count, although there was no documented evidence of what the carb count was for the noon meal.

Also, further review of the MARs for 09/12 revealed, on 09/18/12 at 4:30 PM, Patient #1's accucheck was 189 before meals and was 313 at 5:30 PM after meals. According to the MAR, four (4) units of SSI was administered as opposed to three (3) units per calculation of the Physician's Orders. In addition, Patient #1 received 4 units of Novolog SSI per the carb count, although there was no documented evidence of what the carb count was for the supper meal.

According to the 09/12 MAR, on 09/19/12 at 7:30 AM, Patient #1's accucheck was 187 and after meals at 8:30 AM was 375. Review of the MAR revealed zero (0) units of Insulin was administered as opposed to four (4) units per calculation of the Physician's orders. The patient also received two (2) units of Novolog SSI related to the carb count although there was no documented evidence of what the carb count was for the breakfast meal. In addition, on 09/19/12 Patient #1's accucheck was 303 at 11:30 AM before meals and 465 at 12:30 PM after meals. According to the MAR the patient received three (3) units instead of six (6) units as per calculation of Physician's Orders. In addition, the patient also received 5 units of Novolog SSI per the carb count, although there was no documented evidence of what the carb count was for the noon meal.

Interview, on 09/26/12 at 9:45 AM, with Registered Nurse (RN) #2, who had had administered Insulin to the patient during the hospitalization, revealed the nurses checked the patient's accucheck before and after meals, added up the carbs consumed at mealtime according to what the patient ate, and administered insulin depending on the accucheck and the amount of carbs as per Physician's Orders. After reviewing the MAR for 09/12 she indicated there was inconsistency with the amount of Novolog SSI which was administered and what should have been administered as per the accuchecks. She stated the nurses did not document the amount of carbs consumed on the MAR or on any other form; however, stated the amount of carbs consumed could be calculated by the amount of insulin administered.

Interview with the Risk Management Registered Nurse, on 09/26/12 at 8:30 AM and 12:00 PM, revealed the facility did audits to ensure two (2) nurses signed off with insulin administration which entailed viewing the amount of insulin in the syringe. She stated the nurses needed education related to insulin administration, and the facility would need to consider having two (2) nurses check the Physician's Order on the MAR as well as have (2) two nurses check the amount of insulin in the syringe to be administered during medication pass.

Interview, on 09/26/12 at 12:00 PM, with the Director of Nursing revealed the MAR indicated incorrect dosages were received for Novolog SSI on the 09/12 MAR. She stated she was unsure why the nurses were not administering the correct dosages and she was unaware of any audits related to checking insulin dosages per the MAR and Physician's Orders. She further indicated the nurses may need to document the amount of carbs consumed to enable staff to have a way of ensuring the correct amount of insulin was administered by the carb count.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to reassess the patient's discharge plan when there were factors that affected the continuing care needs or the appropriateness of the discharge for one (1) of ten (10) sampled patients (Patient #5).

Record review revealed Patient #5 was discharged from the hospital on 08/06/12 and was sent home by a taxi, although the patient was known to the hospital staff to be non-compliant with medication and had an emergency legal guardian. There was no documented evidence the emergency legal guardian was notified of Patient #5 being discharged on this date. The day after discharge, on 08/07/12, Patient #5 was again hospitalized at another hospital for psychiatric evaluation and treatment related to aggression towards her/his family.

The findings include:

Review of the facility "Discharge/Aftercare Planning" policy, revised 05/07, revealed the discharge plan was to include timely and direct communication with and transfer of information to other programs, agencies or individuals that will be providing continuing care.

Review of Patient #5's medical record revealed an admission date of 07/19/12. Review of the Psychiatric Admission Assessment revealed the admission diagnoses included Bipolar Disorder I, manic with rapid cycling and possible elements of cognitive slippage, Diabetes Mellitus, Hypertension, Hypothyroidism, and Arthritic pain. The Chief Complaint/Reason for admission was: Acutely manic.

Further review of the medical record revealed an Emergency Guardianship was ordered on 07/25/12 appointing Patient #5's sister as emergency guardian, and stating due to significant mental problems the patient was unable to care for self and her/his Physician felt she/he needed help in taking care of self and finances. "The above findings of danger requires the provision to respondent of the following assistance: handling financial responsibilities, determining living arrangements, consenting to medical procedures and medical transport".

Review of the Progress Note, dated 08/02/12 at 2:30 PM, revealed there was a meeting which included the Therapist, the patient's sister, and the patient to discuss the patient's progress, safety planning, and aftercare. Further review revealed the patient became verbally aggressive, yelling, cussing, and was intimidating by getting into personal space and pointing fingers at patient's sister. Discussion included discharging home and requiring assistance with monitoring medication, finances, housekeeping, Activities' of Daily Living (ADL's) and transportation.

Review of the Progress Notes, dated 08/05/12 at 1:00 PM, revealed the nurse contacted the patient's guardian today about plans to discharge patient today. The Note stated the guardian reported to staff that she would not come and get the patient and that it was the hospital's responsibility to place the patient somewhere.

Review of the Progress Notes, dated 08/05/12 at 6:00 PM, revealed the patient was agitated and going in and out of her/his room, tearful at times, shouting loudly, slamming the door to her/his room, and coming to staff frequently to ask if someone was coming to get her/him and take her/him home.

Review of the Continuing Care/Discharge Plan, signed by the Therapist on 08/06/12, revealed there was a family session on 08/01/12. The plan stated the patient was to return home, no guns, sister will lock up all other lethal weapons (knives, etc) and all lethal medications. Sister will monitor patient's medications. The Plan further stated this was reviewed with the patient's sister and the patient was to follow up with Mountain Comprehensive Care Center for individual therapy and medication management.

Review of the Progress Note by the Therapist, dated 08/06/12 at 4:29 PM, revealed a phone call was made to the patient's sister/emergency guardian to notify her the patient was requesting discharge today. The Therapist spoke with the brother in law and he expressed concerns that the patient was verbally aggressive and intimidated his wife (patient's sister). He was concerned that his wife would not be safe in the car with the patient and the therapist discussed patient taking a taxi cab home. The brother in law was concerned the patient was discharging and not able to care for self. The Note further stated the Therapist had discussed home health and the patient refused. The Therapist faxed medical records to another facility per the sister's request.

Review of the Physician's Order, written 08/06/12 revealed, may discharge today with a taxi. Staff must document that staff has a taxi and that patient is responsible for paying the bill.

Interview with the patient's sister/emergency guardian, on 09/21/121 at 9:40 AM, revealed she had received a message on her answering machine (she was unsure of the date) stating the patient was to be picked up for discharge on 08/07/12 and then she received a second message on 08/06/12 that the patient had already been discharged and was placed in a taxi. Continued interview revealed the facility did no discharge planning with her and that she found the discharge papers from the facility in the patient's belongings after the patient had been discharged. She stated she found the Continuing Care Discharge Plan which talked about the sister/emergency guardian ensuring all lethal weapons were locked up and ensuring the monitoring of the patient's medication. She further stated this information was never discussed with her. She stated she did attend a meeting days prior to discharge with the patient and the Therapist and the patient was threatening her because she had obtained emergency guardianship. Further interview revealed she did not feel the patient was ready for discharge as the patient was not stable as evidenced by her/his behavior after discharging home. She stated the next day after the patient was sent home, she/he went to the bank and started causing a disruption and trying to give away money. She stated the patient had to be hospitalized at Appalachian Regional Hospital.

Review of the Appalachian Regional Hospital History and Physical, dated 08/07/12, revealed the patient was admitted on an involuntary basis as apparently the patient had become aggressive toward family, was angry and shouting. The patient was subsequently admitted for psychiatric evaluation and treatment.

Interview, on 09/25/12 at 11:30 AM, with the facility Attending Psychiatrist, revealed the patient was admitted with Bipolar Disorder and was initially manic and agitated. During the stay at the facility the medications were adjusted and he felt PATIENT #5 was safe and had stayed at the facility an unnecessary amount of time and no longer met the criteria needed for hospitalization. He explained the criteria for discharge included; ensuring the patient was not homicidal/suicidal, or psychotic. He further stated the patient's Bipolar Disorder was stable and the personality disorder was unchanged. Further interview revealed he felt the patient could take care of self at home with a family member checking on her/him although the patient was non compliant with medications. He was unaware at the time the patient was discharged, that the legal guardian had not been notified. He stated it was the facility's policy to notify the guardian when a patient was being discharged and it was a mistake to send the patient home without notification to the emergency guardian.

Interview with the Therapist, on 09/25/12 at 1:15 PM, revealed she was aware of Patient #5's emergency guardianship. She stated on 08/06/12 she did not speak with the emergency guardian because the guardian was unavailable, but spoke with the emergency guardian's husband and told him the patient was being discharged by taxi. She further stated at the time of discharge she did not discuss with the emergency guardian about ensuring lethal weapons and medications were unavailable to the patient because she had discussed this in the meeting on 08/01/12. Further interview revealed she felt the patient was safe to go home by taxi and that she/he no longer met the criteria for hospitalization which included homicidal/suicidal or psychotic and this was discussed with the Psychiatrist on 08/06/12. Further interview revealed the patient should not have been discharged without notification to the legal guardian and the discharge could have been canceled until the next day while staff tried to reach the legal guardian.

Interview, on 09/25/12 at 2:45 PM, with Registered Nurse (RN) #5 revealed he was not the nurse assigned to the patient during the discharge; however, he had gone over the Continuing Care Discharge Plan related to the medications with the patient. He stated he was out of the loop regarding the discharge planning and was unaware she/he had a legal guardian. He stated if a patient had a legal guardian, the legal guardian should be educated on the medications as well as the patient and the discharge instructions.

Interview, on 09/26/12 at 2:30 PM, RN #4 revealed he was the nurse assigned at the time of discharge and he was unaware the patient had a legal guardian. He stated the patient left at shift change and he was not involved in the discharge planning.

Interview, on 09/26/12 at 8:30 AM, with the Risk Management Nurse revealed emergency guardianship was new to the hospital and the Psychiatrist and Therapist felt it was a violation of patient's rights to keep the resident in the hospital. However, she stated the emergency guardian should have been informed of the discharge and the staff should not assume that another family member would notify the emergency guardian of the discharge. She stated the emergency guardian was not compliant and cooperative with the discharge plan; however, the facility could have notified a State Agency to ask for guidance on what to do.

Interview, on 09/26/12 at 12:20 PM, with the Director of Nursing (DON), revealed according to policy, the legal guardian should have been notified prior to the discharge.