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WEST CHESTER HOSPITAL 7700 UNIVERSITY DRIVE WEST CHESTER, OH 45069 Dec. 12, 2017
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on medical record review, facility discharge planning policies, and staff interviews, the facility failed to ensure staff provided discharge needs related to the patient's known diagnosis of diabetes. This affected Patient #4. A total of 10 medical records were reviewed.

Findings include:

The medical record of Patient #4 was reviewed on 12/11/17 at 11:45 AM. Patient #4 was transported via ambulance to the facility's Emergency Department on 10/08/17 at 9:03 PM with complaints of multiple falls during the week. The Emergency Medical Services (EMS) Run Report noted the patient had a medical history of diabetes. An Emergency physician's History and Physical noted a medical history of diabetes mellitus, atrial fibrillation, and multiple falls. The Emergency Department physician completed medication reconciliation on 10/08/17 at 11:18 PM. The reconciliation listed 8 medications, none of which were prescribed to treat diabetes.

The patient's Emergency Department course stated the patient's blood sugar in the Emergency Department was 71, within a normal range.

The patient was admitted to one of the facility's medical surgical units on 10/08/17 at 11:59 PM. A staff nurse from the medical surgical unit was noted to audit the medication reconciliation on 10/09/17 at 12:16 AM. Although no medication taken to treat diabetes was noted in the medication reconciliation, orders for Humalog insulin (a fast-acting insulin used to control blood sugar spikes that happen naturally with eating) 0-5 units 3 times daily before meals and 0-4 units at bedtime were noted.

At 02:52 AM the Medication Administration Record (MAR) noted the bedtime dose was not given due to the medication not being available. The medical record did not speak to why Humalog insulin would not be available.

Staff B, a staff nurse, was interviewed on 12/12/17 at 10:00 AM and asked why insulin would not be available.
Staff B stated: "My best guess is that the nurse chose the wrong drop down but the patient wouldn't have gotten the insulin anyway. It should've been documented."

The admission orders lacked an order for Lantus in the morning or at bedtime. According to the MAR the patient was medicated with 1 unit of Humalog insulin at 06:00 AM on 10/09/17 for a blood sugar of 157. At 2:01 PM on 10/09/17 the patient's blood sugar was 187 and he/she was medicated with 1 unit of Humalog. At 5:48 PM the patient's blood sugar was 265 by point of care testing and he/she was medicated with 3 units of Humalog. A bedtime dose of 3 units of Humalog insulin was administered at 8:46 PM for the patient's blood sugar of 313.

Although the medical record lacked a reason, a physician's verbal order at 12:58 AM on 10/09/17 changed the patient's Humalog insulin dose from a low dose sliding scale (0-4 units) to a high dose sliding scale of 0-8 units 3 times daily to start at 10:00 PM. An order for 29 units of Lantus (long-acting insulin) at bedtime was noted on 10/09/17 at 10:30 PM. The patient was medicated with 7 units of Humalog insulin at 01:00 AM and at 02:00 AM, he/she was medicated with 29 units of Lantus.

Review of laboratory results revealed the patient's hemoglobin A1C (measures average blood glucose over the past 2 to 3 months. An A1C level of 6.5 percent or higher on 2 separate occasions reveals the patient has diabetes) at 05:14 AM on 10/10/17 was 7.

The patient's blood sugar at 8:07 AM was 246. The patient received 3 units of Humalog insulin at 10:50 AM. According to the MAR the patient received no coverage at noon time as his/her blood sugar was within normal range. At 5:13 PM the patient's blood sugar was 327. The patient received 7 units of insulin prior to discharge at 6:15 PM.

The discharge planning assessment was noted in the medical record at 6:49 PM on 10/09/17. The assessment stated that the patient and family were taking part in the discharge plan. The Continuity of Care form noted the patient should be provided a diabetic diet. The form also listed his/her medications. It stated: "Take these medications, which you were already taking." There were no medications to treat the patient's diabetes noted on the list of medications. The Discharge Summary stated that the Continuity of Care form was faxed to a skilled nursing facility (SNF) where the patient was being discharged .

The facility policy titled Discharge Planning was reviewed on 12/12/17 at 9:30 AM. According to the policy the interdisciplinary team will communicate as often as needed to ensure that workable, safe and effective discharge plans are in place in a timely manner. The team will reassess the plan if there are factors that affect the continuing care needs or the appropriateness of the discharge plan and determine if the plan meets the needs of the patient.

Staff A and B were interviewed on 12/12/17 at 4:15 PM. Staff B, a Registered Nurse and Assistant Clinical Manager of Unit Based Case Managers, described the discharge process. Staff B revealed staff conduct multidisciplinary rounds everyday at 9:00 AM. The multidisciplinary team consists of a charge nurse, a case manager, a social worker, a physical therapist or occupational therapist, a pharmacist, and a physician occasionally. Staff B also revealed the discharge process includes a nurse to nurse handoff between the facility nurse caring for the patient at discharge and the nurse assuming care of the patient at the new facility.

It was confirmed with Staff A, Staff B, and Staff C on 12/12/17 at 4:30 PM that the discharge protocol was not followed by staff as the patient was discharged to a new facility and the new facility was not made aware of the patient's need for insulin.