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Based upon reviews of medical records, Quality Assurance (QA) Program and associated data, incident/accident reports, and staff interview, the hospital failed to ensure the QA Program tracked all quality indicator for patient falls. This was evidenced by the failure to include patient #1's fall on 12/08/14 on the December 2014 quality indicators that analyzed patient falls. Findings:

Review of patient #1's medical record revealed according to the nursing notes, on 12/8/14 at 11:00 p.m. the patient had fallen to the floor at the bathroom entrance.

Review of the incident/accident reports for December 2014 and the QA Program quality indicators for patient falls for December 2014, January 2015 and February 2015, revealed patient #1's fall was not identified.

Interview with S4RN/QA (Registered Nurse/Quality Assurance) Director on 03/03/15 at 3:15 p.m. revealed she was on vacation in December and the incident report for patient #1's fall went through the corporate office and S3 RN/DON (Registered Nurse/Director of Nursing) had the report. Since she did not receive the incident report, it was not included in the QA data collected for patient falls.

Based upon record review and staff interviews, the hospital failed to ensure the nursing staff kept a current nursing care plan for 3 of 6 patients (#1, #2, #5). This was evidenced by the failure to update patient #1 and #2's care plan related to actual falls, and patient #5's care plan related to Insulin Dependence Diabetes Mellitus and the administration of insulin. Findings:

Review of patient #1's medical record revealed on 12/08/14 at 11:00 p.m. the patient fell to the floor at the bathroom entrance. Review of the plan of care revealed the plan failed to be updated to include interventions related to patient safety and falls.

Review of patient #2's medical record revealed that the patient was admitted on 2/5/15 and was assessed to be at high risk for falls. Further review of the record revealed there was no plan of care initiated upon admit, related to patient safety and falls. Review of the nurses notes revealed that the patient fell on 2/28/15 at 8:00 a.m., sustaining a one inch laceration to her head.

Review of patient #5's medical record revealed the patient had a diagnosis of diabetes and was receiving insulin according to a sliding scale. Review of the patient's plan of care revealed the plan failed to be undated to include interventions related to diabetes and insulin administration.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with physician orders and hospital policy for 1 (#5) of 6 (#1-6) sampled patients reviewed for medication administration.
Findings:

Patient #5
Review of the hospital policy titled Blood Glucose Monitor revealed in part the following: A comment must be entered for all critical values. A critical result is any result less than 40 mg/dL and greater than 450 mg/dL. If a critical value is obtained, documentation should reveal either lab draw and MD notified or no lab draw depending on provider's orders. Normal reference range for blood glucose is 70-105mg/dL.

Review of the record for patient #5 revealed the patient was admitted to the hospital on 3/2/15 at 7:30 p.m. with diagnoses including diabetes and chronic obstructive pulmonary disease. Review of the admit physician orders revealed an order for accuchecks before meals and at bedtime. No sliding scale insulin was ordered upon admit to the hospital. There was no documented evidence that any accuchecks were obtained on 3/2/15.

Review of a telephone order from the patient's physician dated 3/3/15 at 6:00 a.m. revealed orders for Humalog sliding scale:
If blood sugar is 150-200, give 2 units subcutaneously;
If blood sugar is 201-250, give 4 units subcutaneously;
If blood sugar is 251-300, give 6 units subcutaneously.

Further review of the record revealed the first documented time that the patient's blood sugar was checked was on 3/3/15 at 6:00 a.m., with a result of 485. Documentation on the form titled Insulin Control Sheet revealed the nurse administered 6 units of Humalog per sliding scale at that time; however, there were no physician orders regarding how much sliding scale insulin to administer for this high blood sugar reading. There was no evidence that the patient's physician was notified of the blood sugar that was outside the parameters of the sliding scale for Humalog insulin.

Review of the form titled Critical Test Result Notification dated 3/3/15 at 6:22 a.m. revealed that the lab notified the patient's nurse regarding a blood sugar of 517. Further review of the form revealed that the nurse documented that the patient's physician was not notified because the patient was on Prednisone 20mg twice daily.

Further review of the record revealed the following blood sugar/accucheck results:
3/3/15 at 11:30 a.m., result of 426 with 6 units of sliding scale Humalog administered
3/3/15 at 4:30 p.m., result of 402 with 6 units of sliding scale Humalog administered
3/3/15 at 9:00 p.m., result of 568. Nurses notes dated 3/3/15 at 9:00 p.m. revealed that "sliding scale units provided", but no documentation of how many units administered.
3/4/15 at 5:00 a.m., result of 385. There was no documentation of any insulin given.

On 3/4/15 at 2:30 p.m., S3Director of Nursing reviewed the patient's record with the surveyor and confirmed that the nurses had been administering 6 units of Humalog insulin for blood sugars over 300, but there was no physician order for that. S3Director of Nursing further confirmed that there was no documented evidence that the physician was notified of the patient's high blood sugars in order to obtain sliding scale parameters for blood sugars above 300.



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