HospitalInspections.org

Based on record review and interview the hospital failed to include the patient's representative in the implementation of the plan of care for 1 of 8 sampled patients (#5) as evidenced by failing to provide a trapeze for the bed of patient #5 so she could turn herself as requested by the patient's representative. Findings:

Review of the documentation from a meeting held with the representative of patient #5 on 08/15/11 revealed that "Action Taken" for concern #5 was documented as "Director of Therapy requested Trapeze from (host facility) to be delivered to room. Verify with Charge Nurse during shift that it arrived. Also assured that wedge was in room and nursing notified."

Review of the Physician's Orders in the Medical Record of patient #5 revealed an order dated 08/29/11 at 1450 (2:50 p.m.) that read "Trapeze for Bed." The order was documented as a verbal order from S5MD taken by S10LPN.

In an interview on 09/26/11 at 10:30 a.m. with S10LPN he stated that on 08/29/11 the representative of patient #5 called the nurses station requesting a trapeze bar for patient #5. S10LPN stated he immediately ordered a trapeze for patient #5.

Review of a document titled "Department Info Gram", a computerized "note" system for communication of request from Louisiana Extended Care of Louisiana and the host hospital's maintenance department, revealed a request that read in part: "Message: Can someone please come and put the trapeze on bed for patient in room "a". Thank You." Review of the entire message and attempts by S1COO could confirm no date of the request.

In an interview on 09/26/11 with S1COO he stated he "is sure that the request for the trapeze for patient #5 went out on the day he spoke to patient #5's representative." S1COO could not find any dated item to indicate the trapeze was installed nor could he explain why patient #5's representative would call for a trapeze on 08/29/11 if on was already installed.

Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated and supervised the care for 1of 8 sampled patient's (#5) as evidenced by insulin not being administered in accordance with the physician's ordered sliding scale and capillary blood glucose (CBG) results not being documented. Findings:

Review of the Admission Order's for patient #5 dated 07/28/11, with no time, revealed an order to "Initiate Louisiana Extended Care Hospital of Lafayette's CBG (capillary blood glucose) Scale."

Further review of the Physician's Orders revealed S5MD ordered CBG's to be checked on patient #5 ac (before meals) and hs (hour of sleep - normally 9:00 p.m.). Regular Insulin was ordered and the scale to be used for the ac CBG's was as follows:

Less than 60 mg (milligrams)/dl (deciliter) = give 12.5 gm (gram) (1/2 amp) D50W (Dextrose 50% - concentrated sugar solution given intravenously) or 1 mg Glucagon (medication used to raise blood sugar) SQ (subcutaneously - under the skin) if no IV (intravenous) access, recheck CBG and notify MD.
61 - 120 mg/dl No Insulin.
121 - 170 mg/dl 2 units.
171 - 220 mg/dl 4 units.
221 - 270 mg/dl 6 units.
271 - 320 mg/dl 8 units.
321 - 370 mg/dl 10 units.
Greater than 370 mg/dl 12 units, follow Hypoglycemia/Hyperglycemia Protocol per P&P (policy and procedure) and notify Physician.

The Physician's Order for the hs CBG was as follows:
71 - 220 - no insulin.
221 - 270 - 1 unit.
271 - 320 - 3 units.
321 - 370 - 4 units.
> (greater than) 370 - 6 units.

Review of a document titled "Louisiana Extended Care Hospital of Lafayette Diabetic Flow Chart" revealed the following:

08/01/11 at 0600 (6:00 a.m.) the Accu-check (CBG) reading was documented as 123 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/02/11 at 1630 (4:30 p.m.) the Accu-check (CBG) reading was documented as 168(mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/03/11 at 1130 (11:30 a.m.) the Accu-check (CBG) reading was documented as 193 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 4 units of Regular Insulin.

08/06/11 at 1100 (11:00 a.m.) the Accu-check (CBG) reading was documented as 119 (mg/dl). The documentation indicates 2 units of insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 0 units of Regular Insulin.

08/06/11 at 1600 (4:00 p.m.) the Accu-check (CBG) reading was documented as 123 (mg/dl). The documentation indicates 4 units of insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/12/11 at 1100 (11:00 a.m.) the Accu-check (CBG) reading was documented as 134 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/13/11 at 1100 (11:00 a.m.) the Accu-check (CBG) reading was documented as 138 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/19/11 at 1130 (11:30 a.m.) the Accu-check (CBG) reading was documented as 144 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/21/11 at 1600 (4:00 p.m.) the Accu-check (CBG) reading was documented as 125 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/22/11 at 0600 (6:00 a.m.) the Accu-check (CBG) reading was documented as 126 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/23/11 at 0630 (6:30 a.m.) the Accu-check (CBG) reading was documented as 140 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/25/11 at 0600 (6:00 a.m.) the Accu-check (CBG) reading was documented as 136 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/27/11 at 1630 (4:30 p.m.) the Accu-check (CBG) reading was documented as 151 (mg/dl). The documentation indicates no insulin was administered. Review of the Physician's Order revealed patient #5 should have been given 2 units of Regular Insulin.

08/27/11 at 2100 (9:00 p.m.) the Accu-check (CBG) reading was not documented as being done for patient #5 per the Physician's Order.

08/30/11 at 0600 (6:00 a.m.) the Accu-check (CBG) reading was documented as 405 (mg/dl). The documentation indicates 12 units of insulin was administered. Review of the nursing documentation revealed no documentation that the Hypoglycemia/Hyperglycemia Protocol was followed or that the Physician was notified per the Physician's Order.

In an interview on 09/23/11 at 1:32 p.m. with S1Administrator and S2DON both confirmed the missed doses, incorrect doses, and failure to notify the Physician of a CBG > 370 mg/dl. Both further confirmed there were no medication variance forms for the missed and incorrect doses.

Review of a hospital policy titled "Medication Variances", policy number: 9-4.15.0, effective July 2007, last revised 10/08, presented as current policy, revealed the following: "Purpose: To establish a policy and procedure to define and report medication variances...Monitoring Variance: A variance originating from a lack of necessary monitoring or lack of interpretation/appropriate action for selected drugs...These variances include, but are not limited to:...Monitoring results not noted/acted upon...Protocol for Reporting Medication Variances: When a medication variance is discovered, (whether or not patient injury has occurred), the incident must be reported immediately to the charge RN and/or the Director of Nursing and/or the employee's supervisor. The variance should be reported to the physician as soon as possible. The drug administered in error/omitted in error and the action taken should be documented in the patient's medical record. The medication variance will be documented thru the on-line occurrence reporting system..."