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Based on record review and interview the hospital failed to ensure: 1) Blood sugars were reassessed every fifteen minutes time two after a hypoglycemic episode and intervention of Glucagon administration as per policy for 1 of 2 insulin dependent patients with a hypoglycemic episode (#5) out of a total sample of 5 medical records and 2) failing to follow the policy and procedure for notifying the physician for a blood sugar of >350 for 1 of 5 insulin dependent patients (#4). Findings:

1) Blood sugars were reassessed every fifteen minutes time two after a hypoglycemic episode
Review of the medical record for Patient #5 revealed an 83 year old female quadriplegic with a history of a having had a CVA (Cerebrovascular Accident), MI (Myocardial Infarction), Tracheotomy, PEG tube, and Stage II Decubitus Ulcer. Further review of the medical history revealed Patient #5 was an insulin dependent diabetic with diabetic retinopathy, hypertension, and peripheral vascular disease with an amputation of the left hallux.

Review of the Nursing Notes dated/timed 05/23/12 at 0740 (7:40am) revealed Patient #5 had a blood sugar of 40/36. Glucagon 1mg IM (Intramuscular) and the blood sugar was rechecked at 0745 (7:45am) with the results of 54 and again at 0830 (8:30am) with the results of 86. There was no documented evidence the physician was notified of the low blood sugar. Further review of the MAR (Medication Administration Record) and the Nurses Notes dated 04/07/12 through 06/04/12 revealed no documented evidence of any other episode of low blood sugar.

Review of the MAR (Medication Administration Record) for Patient #5 revealed blood sugars were assessed every 6 hours with the results and the amount of insulin administered as ordered were recorded. Further review revealed Patient #5 had a blood sugar of 409 on 05/29/12 at 0400 (4:00am). 10 units of Apidra administered subcutaneously and rechecked at 0530 (5:30am) at which time it was 389. MD S6 notified and new orders for additional coverage was received and administered. Review of all of the blood sugars for Patient #5 from 04/06/12 through 06/04/12 revealed no documented evidence Patient #5 ' s blood sugar reached 400 again.

Review of policy number 9-4.11.1 titled " Hyperglycemic/Hypoglycemic Protocol " dated 05/09 and submitted as the one currently in use revealed .... " B. Conscious patient unable to swallow, IV site cannot be assessed: Administer Glucagon 1mg IM stat: If not contraindicated turn patient on side and observe for vomiting. Recheck CBG (capillary blood gas) every 15 minutes times two. Notify physician of serum results and obtain further orders. " .

2) failing to follow the policy and procedure for notifying the physician for a blood sugar of >350
Review of the medical record for Patient #4 revealed a 69 year old male admitted on 04/26/12 for treatment of Stage IV Sacral Decubitus and MRSA Bacteremia. Review of the Physician's Orders dated/timed 04/26/12@1700 (5:00pm) revealed an order for Levemir 28 units subcutaneous every morning and Novolog 18 units prior to meals and a therapeutic change was approved by the physician for Lantus and Apidra to be used. Further review of the Physician Orders revealed an Endocrinology consult was ordered and new orders received on 05/06/12@4:00pm as follows: Lantus 18 units Subcutaneous at bedtime, Apidra 8 units with meals plus the correction factor (Correction Factor: Blood Sugar of patient minus 120 divided by 50).

Review of the Insulin Orders for the hospital revealed the following sliding scale for glulisine (Apidra) revealed the following:
Low Dose Moderate Dose High Dose
Pre-meal Bedtime and Pre-meal Bedtime and Pre-meal Bedtime and
0100 (1:00am) 0100 (1:00am) 0100 (1:00am)
151-200 1 unit 0 units 2 units 1 unit 3 units 2 units
201-250 2 units 1 unit 4 units 2 units 6 units 3 units
251-300 3 units 1 units 6 units 3 units 9 units 5 units
301-350 4 units 2 units 8 units 4 units 12 units 6 units
>350 5 units 3 units 10 units 5 units 15 units 8 units
Call MD

Review of the Diabetic Flow Sheet for Patient #4 revealed the following dates and times his CBG (capillary blood sugars) were greater than 350: 04/27/12@1630 (4:30pm) - 489; 04/30/12@2100 (9:00pm) - 367; 05/03/12@0700 (7:00am) - 400; 05/03/12#21 (9:00pm) - 454; 05/05/12@1620 (4:20pm); 05/06/12@0730 - 368; 05/07/12@11:30am - 371; 05/08/12@1630(4:30pm) - 411; 05/09/12@100 (4:00pm) - 434; 05/09/12@2100 (9:00pm) - 397; 05/12/12@0730 (7:30am) - 419; 05/13/12@0730 (7:30am) - 420; 05/13/12@11:00am - 407; 05/13/12@1600 (4:00pm) - 542; 05/13/12@2100 (9:00pm) - 494; 05/18/12@11:30am - 383; 05/19/12@11:30am - 442; 05/20/12@1630 (4:30pm) - 371; 05/22/12@0700 (7:00am) - 480; 05/22/12@11:00am - 484; 05/24/12@2100 (9:00pm) - 392; 05/27/12@12noon - 432; and 05/29/12@2100 (9:00am) - 393.

Review of the Nurses' Narrative Notes for Patient #4 revealed no documented evidence the patient was assessed for the signs and symptoms of hyperglycemia or the physician notified for a blood sugar greater than 350 as per protocol for the following dates: 04/30/12, 05/03/12, 05/05/12, 05/06/12, 05/07/12, 05/08/12, 05/09/12, 05/11/12, 05/13/12, 05/19/12, 05/21/12 and 05/22/12.

In a telephone interview on 06/05/12 @9:45am MD S7 explained the use of the correction formula instead of the current sliding scale. Further S7 indicated he did not expect the nursing staff to call him about high blood sugars, but rather by an assessment of the patient and the blood sugar results.

In a face to face interview won 06/05/12 at 1:20pm RN S2 Director of Nursing (DON) indicated the MD should have been called concerning the high blood sugars. Further S2 verified there is no hospital policy or protocol developed for the use of MD S7's correction formula.

Based on interviews and record reviews, the facility failed to ensure insulin was administered as ordered by the practitioner responsible for the patients care for 2 of 5 patients reviewed for insulin administration ( #2, #3). Findings:
A review was made of the hospital policy titled "Medication Administration", Policy Number: 9-4.13.0, revision date 07/11. The policy stated in part: ...All patient medications will be administered per a physician's order and documented on a Medication Administration Record (MAR) ... ...Any drug that is withheld shall be circled and initialed on the MAR ...
...The nurse shall document on the MAR or in the nurses' narrative notes, if necessary, the reason the drug was not given ... ...The physician must be notified if a medication or treatment is held without a specific order to hold the medication or treatment ...

A review was made of the hospital policy titled "Medication Variances", Policy number: 9-4.15.0, revision date 10/08. The policy stated in part: ...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.

Patient #2 Record review revealed Patient #2 was admitted to the facility on 5/23/12 for MRSA (Methicillin-resistant Staphylococcus aureus) bacteremia.
Review of the Admission Orders for Patient #2 dated 5/23/12 at 2100 (9:00 p.m.) revealed a sliding scale Apidra Insulin order with the following parameters: 60-150 (blood glucose level) give 0 units (of Apidra), 151-200 give 1 unit, 201-250 give 3 units, 251-300 give 5 units, 301-350 give 7 units, 351-399 give 8 units, notify MD (Medical Doctor) if BG (Blood Glucose) is 400 or greater.
A Review was made of the Hospital Diabetic Flow Chart for Patient #2. On 5/22/12 at 1630 (4:30 p.m.), an entry was made stating Patient #2's blood glucose level was 192. According to the Admission Orders, 1 unit of insulin should have been administered. No entry was made that insulin had been given. An entry on 6/2/12 at 2100 (9:00 p.m.) revealed Patient #2's blood glucose level was charted as having been 159. According to the Admission Orders, 1 unit of insulin should have been administered. No entry was made that insulin had been given.
Review of the Medication Administration Record and Nurses Notes for Patient #2 dated 5/22/12 at 4:30 p.m. and 6/2/12 at 9:00 p.m. revealed no entries had been documented that insulin had been administered or why the doses had been omitted.
In an interview on 6/5/12 at 1:15 p.m. with the Director of Nursing (DON) S2, he said 1 unit of insulin should have been given to Patient #2 on 5/22/12 at 1630 and 6/2/12 at 2100. S2 verified the omission of the insulin administration had not been charted on the MAR or Nurses Notes. He stated this was a nursing error.

Patient #3
Review of the Medical Record for Patient #3 revealed she had been admitted to the hospital on 5/12/12 with diagnosis that included left leg pain, acute onset Chronic Renal Failure, Bacteremia, and Type-2 Diabetes.
Review of document titled " Insulin Orders " for Patient #3 revealed the following order dated 5/13/12 at 5:00 p.m.: Insulin Sliding Scale - insulin glulisine (Apidra). Administer Subcutaneously.
Blood Glucose mg/dL Pre-meal Bedtime and 0100 (1:00 a.m.)
151-200 2 units 1 unit
201-250 4 units 2 units
251-300 6 units 3 units
301-350 8 units 4 units
>350 call MD 10 units 5 units
A Review was made of the Diabetic Flow Sheet for Patient #3. An entry made on 5/15/12 at 11:30 a.m. revealed Patient #3 had a blood glucose level of 224. According to the insulin orders, 4 units of insulin should have been administered. No documentation was made of insulin being administered. An entry on 5/18/12 at 2100 (9:00 p.m.) revealed Patient #3 had a blood glucose level of 170. According to the Insulin Orders, 1 unit of insulin should have been administered. No documentation was made of insulin being administered.

Review of the Physician ' s Orders for Patient #3 dated 5/31/12 at 4:30 p.m. revealed an order for blood sugars to be checked AC (before meals) and hs (at bedtime). Novolog insulin was ordered to be administered as follows: Blood sugar minus 120 divided by 50 (equals amount of insulin to be administered).

Review of the Diabetic Flow Sheet dated 6/3/2012 at 2100 (9:00 p.m.) for Patient #3 revealed her blood sugar had been recorded as being 185. According to the Physician ' s Orders, she should have been administered 1 unit of insulin. No documentation was recorded that the insulin had been given.

Review of the MAR and Nurses Notes for Patient #3 revealed no documentation on 5/15/12 at 11:30a.m., 5/18/12 at 9:00 p.m. or 5/31/12 at 4:30 p.m. as to insulin being given or the reason for the omission of the insulin.

In an interview on 6/5/12 at 1:20 p.m. with DON S2, he said 4 units should have been given to Patient #3 on 5/15/12 at 11:30 a.m., 1 unit on 5/18/12 at 9:00 p.m., and 1 unit at 5/31/12 at 4:30 p.m. S2 verified the omission of the insulin administration had not been charted on Patient #3 ' s MAR or Nursing Notes.