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Based on review of medical records, policy and procedures, staff and patient interviews, and observation, it was determined that the facility failed to ensure that medications were administered as ordered by the physician for one (#2) of two sampled patients.


Findings were:

Review of patient #2's medical record revealed that on the day of admission, the physician ordered Novolog Insulin 10 units to be administered subcutaneously (SQ-just beneath the skin) three times a day and Lantus Insulin 20 units SQ at bedtime. Review of the Medication Administration Record (MAR) revealed insulin ordered three times a day was to be given at 7:30 a.m., 11:30 a.m., and 5:00 p.m. Insulin ordered to be administered at bedtime was to be given at 9:00 p.m.

Review of the MAR and the Diabetes Flow Sheet revealed that on hospital day #1, there was no documentation of the 5:00 p.m. and 9:00 p.m. insulin doses being administered.

On hospital day #3, the physician ordered the Lantus insulin to be increased to 30 units SQ at bedtime. The MAR revealed that the nurse administered Lantus 20 units SQ at bedtime. On hospital day #5, the patient refused the Lantus 30 units at bedtime and would only agree to receiving Lantus 20 units. There was no documentation that the physician had been notified.

In addition to the routine scheduled doses of insulin, on the day of admission the physician ordered the patient's blood sugar to be checked before meals and at bedtime. The patient was placed on a sliding scale with Novolog Regular Insulin coverage for the following:
? 2 units SQ for blood sugars between 151-200;
? 4 units SQ for blood sugars between 201-250;
? 6 units SQ for blood sugars between 251-300;
? 8 units SQ for blood sugars between 301-350;
? 10 units SQ for blood sugars between 351-400; and
? 12 units SQ for blood sugars over 400 and the nurse was to notify the physician.

Random review of the MAR and the Diabetes Flow Sheet revealed that on the day of admission at 4:00 p.m. the patient's blood sugar was 185, there was no documented evidence that the patient received any insulin. On hospital day #1 at 4:00 p.m., the patient's blood sugar was 345 and the nurse documented that he/she administered Novolog Regular Insulin 20 units SQ. On hospital day #1 at 9:00 p.m., there was no documented evidence of the patient's blood sugar level. On hospital day #2 at 7:00 a.m., the MAR revealed the patient received Novolog Regular Insulin 8 units SQ but on the Diabetes Flow Sheet the nurse had documented that the patient received Novolog Regular Insulin 10 units SQ. On hospital day #3 at 7:00 a.m., and day #7 at 4:00 p.m., there was no documented evidence of the patient's blood sugar level. On hospital day #4 at 11:00 a.m. the patient's blood sugar was 406, and at 4:00 p.m. the patient's blood sugar was 466. Both times the nurse administered the Novolog Regular Insulin 12 units SQ. However, there was no documented evidence that the nurse had notified the physician either time. There were new insulin orders at 8:00 p.m.

Review of facility policy entitled "Medication Administration", policy number NSG-MA-001, last revised 10/16/06, revealed that medications were to be administered by trained, knowledgeable nurses according to the policy and procedure. This policy required medications to be administered per physician order. In addition, this policy required routine medications to be started on the day of the order unless otherwise stated.

Review of facility policy entitled "Medication Safety High-Alert Medications", policy number PCS-10-05, last revised 07/09, required nursing staff to double-check insulin dosage.

During an interview 2:10 p.m. on 03/16/10 in the Conference Room, the Director of Nurses (DON) reviewed the medical record with the surveyor and agreed with the above findings. The DON explained that the diabetic flow sheet was to be used to document all dosages of insulin which would include routine scheduled doses and the sliding scale insulin doses.

On 03/16/10 at 5:00 p.m., the surveyor observed a Licensed Practical Nurse (interview #3) check patient #3's blood sugar results, refer to the MAR to confirm the amount of insulin coverage the patient was to receive, draw up the insulin dosage, have a second nurse (interview #4 a RN) check the insulin dosage with him/her, and administer the insulin as ordered to patient #3. Interviewee #3 stated that the insulin flow sheet was utilized to document the sliding scale coverage. When questioned as to whether the routine scheduled insulin doses were to be documented on the insulin flow sheet, interviewee #3 stated no.

During an interview on 03/16/10 at 5:15 p.m. with patient #3 in the patient's room, the patient stated that the nursing staff had been administering his/her insulin as ordered and as needed.

Review of facility policy entitled "Blood Glucose (sugar) Monitoring", policy number NSG-BG-01, last revised 06/06/03, revealed blood glucose levels were to be obtained by qualified nursing staff. This policy required all certified operators to be evaluated bi-annually at least for competency. In addition, this policy required the results of the patient's blood glucose levels to be recorded on the Diabetes Flow Sheet.