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.

TIMBERLAWN MENTAL HEALTH SYSTEM 4600 SAMUELL BLVD DALLAS, TX Aug. 11, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for one of five diabetic patients (Patient #1) who did not receive insulin according to physician's orders.

Findings included:

Patient #1's Intake assessment dated [DATE] at 1545 reflected the patient's medical diagnosis of Diabetes Mellitus. The patient's medications included 62 units of Lantus (insulin) at night and 25 units of Novolog (insulin) before meals. The patient had his last medication administration "1 to 2 days ago."

Physician Preadmission Examination orders dated 07/16/17 at 1917 reflected an order to administer 62 units of Lantus at night and regular insulin as needed according to a sliding scale.

Initial screening nursing documentation dated 07/17/17 at 2001 reflected Patient #1's blood sugar reading of 214 mg/dL.

Multidisciplinary Progress Notes dated 07/17/17 at 0130 reflected Patient #1's blood sugar reading of 242 mg/dL.

Patient #1's Sliding Scale Insulin Administration, undated, timed at 2000, reflected 62 units of Lantus were ordered to be administered for Patient #1. There was no evidence the insulin was administered. The document reflected a sliding scale order to administer four units of regular insulin for Patient #1's blood sugar readings between 201 mg/dL and 250 mg/dL. There was no evidence Patient #1 received insulin.

Hospital Personnel #10 was interviewed on 08/11/17 at 0940 and confirmed the findings.

Hospital Personnel #5 agreed during an interview on 08/11/17 at 1015 that nursing did not administer insulin to Patient #1 according to physician orders.