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ADVENTHEALTH ORLANDO 601 E ROLLINS ST ORLANDO, FL 32803 April 18, 2019
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to monitor elevated blood glucose (BG) after insulin administration, and prior to discharge for 1 of 2 patient reviewed for elevated BG. (#1).


Findings:

Patient # 1 presented to the Emergency department(ED) on 2/18/19. Her chief complaint was hyperglycemia with a BG level of 420 mg/dL. ED documentation showed patient # 1 received,
Insulin-Lantus10 units, and Humalog 5 units subcutaneously (SC).
The history and physical documentation dated 2/19/19: showed, admitted : 2/18/19 Chief complaint: Hyperglycemia, Visit Reason: Rescue-High Blood sugar. Home medications included: Insulin lispro (Humalog) SC with meals, bedtime. Past Medical History: included: Diabetes type II, [DIAGNOSES REDACTED], kidney failure, bipolar, ESRD, and legal blindness. The history of present illness (HPI) read, "History of kidney transplant left-sided who presented with chest pain. Patient initially presents ...with a left- sided chest pain that radiated to her back for the last 3 days ...In the emergency room ...Laboratory evaluation, showed ...glucose 420 ... Urinalysis showed ...negative ketones ...She was started on IV (intravenous) fluids admitted to the hospital for further evaluation."
Assessment and Plan: "Diabetes mellitus type I, with hyperglycemia, complicated by [DIAGNOSES REDACTED]."
Timed Event note dated 2/28/19 at 2:51PM read, "Pt stated she felt shaky; blood sugar elevated. No shakiness/tremors observed by this RN. Pt consumed milkshake brought to patient by brother-in-law prior to blood glucose check."

Timed Event note on 2/28/19 at 3:37PM read, "Pt left unit with all personal belongings; no complaints of shakiness or concerns expressed by patient."
The "Brief Description of hospitalization " read, "Diabetes mellitus, type 1, A1c 8.8%. A1c indicates an average blood sugar of over 200. Patient was admitted to the hospital blood sugar of 420. Her sugars were brought under control, however she did have some hypoglycemic episodes, which were not consistent with a C-peptide test, nor were they consistent with insulin given from nursing. On day of discharge, she had no hypoglycemic episodes. She did have a final BG of over 500, and was given insulin for this. No recheck was available on the chart, so I contacted the patient for a recheck and she reported blood sugars remained above 500, so I have asked her to return to the hospital."
Review of the ED Physician Sheet: dated 2/28/19 at 7:43PM: Showed: Chief Complaint: Hyperglycemia. HPI: read, "The patient presents with hyperglycemia ...Pt states that she was just discharged this morning from the hospital, which is not what her doctor wanted ...Pt states that when she was at home Dr. (MD- Hospitalist B) called her and told her to re-check her glucose. When she re-checked her blood glucose it was in the 530s, so she came back to the ED."

On 4/18/19 at 12:15PM Risk Manager (RM) C said patient # 1 walked out the hospital door on 2/28/19 at 3:37PM. At 3:21PM 5 units of insulin (Humalog) was administered to the patient. When asked if this was the normal protocol/procedure, the RM said she do not think it is the norm for a patient to be discharged so quickly after an elevated BG and insulin administration.
Patient # 1's clinical records were reviewed by the Director of clinical outcomes. The records showed that patient # 1 had glycemic management in the ED. The patient went from ED to the observation unit, to the Progressive Care Unit on 2/21/19, and was discharged from the hospital on [DATE] at 3:39PM. On 2/28/19 at 2:51PM, patient # 1's BG was 535 mg/dL, at 3:21PM 5 units of insulin was administered. There was no documentation to indicate the patient's BG was rechecked after the insulin was administered, or prior to the patient's discharge from the hospital seven (7) minutes after administration of insulin. Patient # 1 came back to the ED on 2/28/19 at 7:00PM, BG at 7:19 PM was 553mg/dL. The patient was given insulin in the ED, her BG came down, and patient # 1 was discharged home from the ED.

On 4/18/19 at 1:52 PM registered nurse (RN) A said on 2/28/19, she was preparing patient # 1 for discharge home. The patient was in the bathroom and said, "I feel shaky, funny" she checked the patient's BG, and it was 535mg/dL. RN A said she contacted Medical Doctor (MD) Hospitalist B, and obtained an order to give 5 units of insulin now, and no more accu-check. When asked why no more accu-check, RN A said, MD-Hospitalist B suspected patient #1 might be manipulating her BG using her own insulin pen. RN A said the normal procedure would be to give insulin and recheck the patient's BG at the next mealtime. RN A said nurses do not check BG again unless they have an order from the MD to recheck. RN A said when she documented the timed event on 2/28/19, she did not document MD's instructions for no more accu-check. She reported that patient # 1 received the insulin and left the unit shortly after. RN A said she did not ask the patient to stay a while for observation, and said she "guessed" in hindsight she could have followed up, and recheck the patient's BG prior to the patient leaving the hospital. RN A said she did not review the facility's policy and procedure for BG monitoring protocol.

On 4/18/19 at 2:18 PM a telephone interview was conducted with Medical Doctor (MD) Hospitalist B. MD- Hospitalist B said on 2/28/19 he gave order for 5 units of insulin for patient # 1. The MD said when he first read patient # 1's chart, she had low BG. On her last day, the patient asked for something sugary and demanded nursing check her BG, it came back high, she was given 5 units of insulin and sent home. MD-Hospitalist B said he called patient # 1 at home, her BG was still 500 he told her to come back to the ED. The MD said 5 units of insulin should have dropped her BG. He verified that he gave orders to give 5 units of insulin (Humalog) and let her go home, stating it would not have made sense to keep her in the hospital. The MD said keeping patient # 1 in the hospital was not beneficial for her, it was safer to have her at home, her BG were better controlled at home than at the hospital. MD- Hospitalist B said, "If it were a regular patient who was compliant, it might be reasonable to treat her and observe BG in the hospital, before being discharged .

On 4/18/19 at 2:43AM the Director of Clinical Outcomes said she was not involved at the time of the event, but when it became a grievance, she reviewed the protocol, talked with the unit manager and MD-Hospitalist B after the fact. She said, patient # 1's BG fluctuated because of the potential of self- manipulation, and was stable in the 200. The Director of Clinical Outcomes said MD-Hospitalist B said he was looking at patient # 1's pattern of insulin dosage and how she reacted to insulin, and 5 units should have bought her BG down. The Director of Clinical Outcomes said in looking at patient # 1's history, she could understand where it would make sense to have the patient's BG rechecked before discharge. Both RM C and the Director of Clinical Outcomes could not identify documentation regarding MD being notified of patient # 1's elevated BG, or documentation regarding order for no more accu-check in the timed events or provider notification notes. Review of the physician's order showed order for 5 units insulin lispro on 2/28/19 at 3:21PM.
Review of the discharge summary showed, MD did not order a recheck of patient # 1's BG status post insulin administration and prior to discharge home.

The facility's policy and procedure "Glycemic Management PowerPlan" read, "Orders must be reviewed and authenticated by responsible physician ...Select Low, Medium, High, or Custom correction Scale ...correctional scale is to cover elevated BG only ...Do not obtain BG within 3 hours of insulin administration unless otherwise ordered or signs/symptoms of [DIAGNOSES REDACTED]...use for less than 40 units of total insulin required per day and/ or weight less than 70 kg ...BG 350 or greater: AC/q4h 5 units Bedtime/0200 4 units: Give Insulin Correction and Notify Physician ...Blood Glucose Bedside Monitoring POC ...Notify physician if BG 300 mg/dL or greater or 70 mg/dL or less. Inquire about starting IV insulin when BG 300 mg/dL or greater.
Review of patient # 1's clinical records showed no documentation that the patient's BG was rechecked, and results reported to the MD as per protocol.