The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAINT THOMAS MIDTOWN HOSPITAL 2000 CHURCH ST NASHVILLE, TN 37236 Sept. 4, 2012
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, the facility failed to ensure the nursing staff educated patients adequately before discharge for one (#3) of five patients reviewed.

The findings included:

Medical record review revealed patient #3 was admitted to the facility on on July 26, 2012, with complaints to include Shortness of Breath which had increased over the past week. Pertinent medical history included diagnoses of [DIAGNOSES REDACTED]

Review of the History and Physical completed by the physician on July 26, 2012, revealed the patient had "...Diabetes Mellitus uncontrolled...".

Review of physician's admission orders written on July 26, 2012, revealed "...Lantus insulin 15 units each evening; accu checks (blood glucose monitoring) before meals and at bedtime; and sliding scale insulin (specific doses of insulin according to the blood glucose range) with each accu check...". Further review of physician's orders dated July 26, 2012, at 11:27 p.m., revealed "...hold PM dose of Lantus (insulin)...". Continued review of physician's orders dated July 27, 2012, at 7:30 a.m., revealed "...Lantus 10 units at bedtime; Novolog (insulin) 3 units TID (three times daily) before meals...".

Review of Education notes dated July 26, 2012, at 4:59 p.m., revealed "...Diabetes Standards of Care: Given to/Reviewed with Patient and/or Caregiver...". Further review of the education notes dated July 26, 2012, at 8:00 p.m., revealed patient and family were taught via demonstration about "...blood glucose testing and when; blood glucose testing goals; [DIAGNOSES REDACTED] (low blood glucose) signs and symptoms and treatment; medication: oral/insulin/other...". Further review of education notes revealed no documentation there was a return demonstration by the patient of correct insulin administration.

Review of discharge medications dated August 1, 2012, revealed the patient was ordered ..."Lantus insulin 10 units once daily at bedtime; Novolog insulin three times daily before meals and at bedtime, medium sliding scale as instructed...".

Interview with the Nurse Manager of Cardiology, the unit where the patient was admitted , on September 4, 2012, at 11:15 a.m. in the Risk Management conference room, revealed the spouse stated, at discharge, the patient had not received proper education regarding insulin administration. Further interview revealed the hospital has a contract with the Diabetes Center to provide education to patients but the center was not consulted on this patient. Continued interview confirmed there was no nursing documentation the patient had been educated on insulin administration and calculating dosages of sliding scale insulin before discharge."

Interview with the Risk Manager on September 4, 2012, at 12:30 p.m., in the Risk Management office, confirmed the patient did not receive education on insulin administration and calculating dosages on the sliding scale.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, the facility failed to develop an appropriate discharge plan to meet the needs of patients for one (#3) of five patients reviewed.

Medical record review revealed patient #3 was admitted to the facility on on July 26, 2012, with complaints to include Shortness of Breath which had increased over the past week. Pertinent medical history included diagnoses of [DIAGNOSES REDACTED]

Review of the History and Physical completed by the physician on July 26, 2012, revealed the patient had "...Diabetes Mellitus uncontrolled...".

Review of physician's admission orders written on July 26, 2012, revealed "...Lantus insulin 15 units each evening; accu checks (blood glucose monitoring) before meals and at bedtime; and sliding scale insulin (specific doses of insulin according to the blood glucose range) with each accu check...". Further review of physician's orders dated July 26, 2012, at 11:27 p.m., revealed "...hold PM dose of Lantus (insulin)...". Continued review of physician's orders dated July 27, 2012, at 7:30 a.m., revealed "...Lantus 10 units at bedtime; Novolog (insulin) 3 units TID (three times daily) before meals...".

Review of Education notes dated July 26, 2012, at 4:59 p.m., revealed "...Diabetes Standards of Care: Given to/Reviewed with Patient and/or Caregiver...". Further review of the education notes dated July 26, 2012, at 8:00 p.m., revealed patient and family were taught via demonstration about "...blood glucose testing and when; blood glucose testing goals; [DIAGNOSES REDACTED] (low blood glucose) signs and symptoms and treatment; medication: oral/insulin/other...". Further review of education notes revealed no documentation there was a return demonstration by the patient of correct insulin administration.

Review of discharge medications dated August 1, 2012, revealed the patient was ordered ..."Lantus insulin 10 units once daily at bedtime; Novolog insulin three times daily before meals and at bedtime, medium sliding scale as instructed...".

Interview with the Nurse Manager of Cardiology, the unit where the patient was admitted , on September 4, 2012, at 11:15 a.m. in the Risk Management conference room, revealed the spouse stated, at discharge, the patient had not received proper education regarding insulin administration. Further interview revealed the hospital has a contract with the Diabetes Center to provide education to patients but the center was not consulted on this patient. Continued interview confirmed there was no nursing documentation the patient had been educated on insulin administration and calculating dosages of sliding scale insulin before discharge."

Interview with the Risk Manager on September 4, 2012, at 12:30 p.m., in the Risk Management office, confirmed the patient did not receive education on insulin administration and calculating dosages on the sliding scale.