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Based on observation, record review, and interview the hospital failed to meet the Condition of Participation for Nursing Services by:

1) Failing to ensure that policies/procedures were developed and implemented regarding the need for routine nursing assessments/reassessments of patients who receive insulin medication while hospitalized. The failure to monitor patient's blood glucose readings prevents nursing personnel from knowing when a patient's blood glucose level is not being maintained at a safe range and to assist nursing personnel in providing nursing interventions for rapid decline/increases in blood glucose. The failure to have a policy and procedure to direct nursing staff in this area resulted in patient #2 experiencing a severe decline in blood glucose following insulin administration without nursing staff being aware and required the patient to be transferred to another hospital for medical care. (See findings cited at A0395)

2) Failing to ensure Patient Assessments were performed as needed by: a) failing to have the Registered Nurse assess patients with a significant change in condition for 1 of 1 death records reviewed out of a total sample of 5 (Patient #5). b) failing to re-assess hyperglycemic patients who received insulin to ensure that blood glucose readings returned to a safe range for 1 of 5 sampled patients (#2). Patient #2 was given insulin for severe hyperglycemia (446 milligrams per deciliter Capillary Blood Glucose). The patient's capillary blood glucose was reassessed one time only after receiving 12 units of insulin at bedtime (10:00 p.m. Capillary Blood Glucose of 292) and not re-assessed again until 5:25 a.m. when the patient was found unresponsive with a glucose level of 27. This resulted in the patient having to be transferred to another hospital's ICU (Intensive Care Unit) after the patients blood glucose declined to a critical level of 27 milligrams per deciliter. (See findings cited at A0395).

3) Failing to ensure that blood glucometer machines used to determine blood glucose readings for the administration of oral and/or injectable insulin to patients were determined accurate as evidenced by the failure of nursing staff to perform quality controls on the glucometer machines according to manufacturer's recommendations. Solutions used by nursing staff to test the blood glucose monitoring machine for accuracy of the "high" level readings had not been used since 8/23/2010 and the solutions used to detect the accuracy of the "low" level readings had expired. Nursing staff failed to report and take immediate action to correct and/or remove glucometers from use when glucometer test results were outside of the expected/acceptable range for the control solutions (See findings cited at A0395).

4) Failing to ensure that nursing staff were knowledgeable of the need to use oxygen during resuscitation procedures. This was evident in 1 of 1 death record reviewed out of a total sample of 5 (#5) as evidenced by nursing staff ventilating a patient with an ambu/ room air. The ambu had not been connected to oxygen. (See findings cited at A0395).

5) Failing to ensure the hospital policy titled, "Death of a Patient" was followed relative to pronouncement of death, notification of Medical Examiner, and notification of Louisiana Organ Procurement Agency (LOPA) for 1 of 1 death record reviewed out of a total sample of 5 (#5). This practice resulted in Patient #5 being sent to the funeral home without having LOPA notified or receiving an order from the coroner or physician indicated the body could be released to the funeral home. (See findings cited at A0395).

6) Failure to update treatment plans (patient care plans) to include diabetes and/or sliding scale insulin for 4 of 5 diabetic patients reviewed (#2, #3, #4, #5) (See findings cited at A0396).

8) Failing to ensure the Registered Nurse did not delegate to unlicensed nursing personnel capillary blood glucose testing on patients that required sliding scale insulin based on CBG (Capillary Blood Glucose) results. This is in violation of the Louisiana State Board of Nursing Requirements. (See findings cited at A0397).


An immediate jeopardy situation was identified on 9/28/2010 at 5:16 p.m. and reported to the Hospital Administrator S1 and Director of Nursing S2. The immediate jeopardy situation was a result of the following:
1) failure of nurses to re-assess hyperglycemic patients who received insulin to ensure that blood glucose readings returned to a safe range. Patient #2 was given insulin for severe hyperglycemia (446 milligrams per deciliter) and her capillary blood glucose was not re-assessed from 10:00 p.m. until 5:00 a.m. after the patient had received 12 units of regular insulin at 8:00 p.m. with a rapid decrease to 292 at 10:00 p.m. This patient was transferred to an acute care hospital's ICU (intensive care unit) after her blood glucose was found to be 27 on 8/28/2010 at 5:00 a.m. Patient #2 was unresponsive to verbal stimuli and responded to sternal rub by blinking her eyes.
2) failure to ensure the Registered Nurses did not delegate capillary blood glucose testing to unlicensed personnel for patients that were on insulin to be administered by a sliding scale based on the results of the capillary blood glucose testing. (See findings cited at A0397).
3) failure to ensure that blood glucose readings were accurate due to the failure to perform accurate quality checks on the machines. The hospital had no High Control Solution since 8/23/2010 and the Low Control Solution was expired.
4) failure to ensure that staff report and take action on glucometer test results that were outside of the expected/acceptable range for the control solutions.
5) Failure to ensure that policies/procedures were developed and implemented regarding the assessment/re-assessment of patients receiving insulin to ensure that blood glucose readings were maintained at a safe range.
6) Failure to ensure that care plans were updated to include sliding scale insulin administration to direct care provided to these (diabetic) patients (See findings cited at A0396).

A corrective action plan was submitted by the hospital on 9/30/2010 at 1:50 p.m. to address the immediate jeopardy situation which revealed:
1) the hospital had implemented a new Hyperglycemic Policy which outlined follow up assessments by nursing staff for patients with severe hyperglycemia which required glucose testing every two hours x 3 for patients with elevated glucose levels.
2) the hospital's Director of Nursing was educating all nurses prior to the start of their shift regarding the new policy for re-assessing patients with severe hyperglycemia, the new policy which only allowed Registered Nurses or Licensed Practical Nurses to perform capillary blood glucose testing or quality control testing of the hospital's glucometers.
3) the hospital changed their practice by instituting a new policy which only allowed Registered Nurses or Licensed Practical Nurses to perform capillary blood glucose testing or quality control testing of the hospital's glucometers.
4) the hospital's implementation of Quality Control monitoring to evaluate compliance with glucometer control testing to ensure the control solution was within the expiration date and the control testing was within the required parameters to ensure accuracy of testing.
5) the hospital's modifying of care plans to ensure episodes of hypo and/or hyper glycemia were included for all patients on sliding scale insulin.

As a result of the hospital's implementation of the action plan, the immediate jeopardy situation was removed on 9/30/2010 at 1:50 p.m. The hospital's noncompliance remains at the Condition Level.

Based on record review and interview the hospital failed to ensure a patient's grievance was addressed according to hospital policy by failing to identify the grievance and treating it as a complaint (rather than a grievance) for 1 of 1 grievance reviewed (Patient #2). Findings:

Review of a "Patient/Family Complaint Form" dated 9/01/2010 regarding Patient #2 revealed the patient's (#2's) daughter had complained that nursing staff had not been checking on her mother regularly and she thought they might have been watching television and/or sleeping during the night shift. Further review revealed Patient #2's daughter had stated, "this is not the end of this". Further review revealed the section titled, "DON (Director of Nursing) Review and Follow up" revealed "reviewed charting- accuchecks completed and coverage documented - nurse interviewed (RN S11) Administrator notified."

Review of the entire "Complaint" file for Patient #2 revealed no documented evidence that the incident was ever identified as a Grievance and no documented evidence that the Patient and/or Patient's family was ever provided with a written notice of it's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

During a face to face interview on 9/28/2010 at 2:30 p.m., Director of Nursing (DON) S2 indicated she was new to the position of DON and was not familiar with the differences between complaints and grievances. S2 indicated she had not identified Patient #2's grievance as such and therefore had not proceeded with the hospital policy regarding grievances. S2 indicated she had never planned on providing the patient and/or family with a written response regarding the grievance investigation. S2 indicated she had not identified issues brought forth by any patients and/or family members as grievances since she took the position as DON. S2 further indicated she had not discovered that the hospital had no policy for treating patients with critical level Capillary Blood Glucose levels in the hospital during her investigation of what she had identified as a complaint (rather than a grievance) by Patient #2's daughter (See findings cited at A0395).

Based on record review and interview the hospital failed to ensure a patient's grievance was followed up with a written notice of it's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 grievances reviewed (Patient #2). Findings:

Review of a "Patient/Family Complaint Form" dated 9/01/2010 regarding Patient #2 revealed the patient's (#2's) daughter had complained that nursing staff had not been checking on her mother regularly and she thought they might have been watching television and/or sleeping during the night shift. Further review revealed the section titled, "DON (Director of Nursing) Review and Follow up" indicated "reviewed charting- accuchecks completed and coverage documented - nurse interviewed (RN S11) Administrator notified." Further review revealed Patient #2's daughter had stated, "this is not the end of this".

Review of the entire "Complaint" file for Patient #2 revealed no documented evidence that the incident was ever identified as a Grievance and no documented evidence that the Patient and/or Patient's family was ever provided with a written notice of it's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

During a face to face interview on 9/28/2010 at 2:30 p.m., Director of Nursing (DON) S2 indicated she was new to the position of DON and was not familiar with the differences between complaints and grievances. S2 indicated she had not identified Patient #2's grievance as such and therefore had not proceeded with the hospital policy regarding grievances. S2 indicated she had never planned on providing the patient and/or family with a written response regarding the grievance investigation.

Based on record review and interview the hospital failed to ensure hospital policy was followed by failing to ensure a credentialed physician with privileges at the hospital report coroner's cases to the coroner and failing to document a death summary for 1 of 1 patient deaths reviewed (#5). Findings:

Review of the hospital policy titled, "Death of a Patient, N 2.041 (no documented date)" presented by the hospital as their current policy revealed in part, "When a patient death occurs from Natural Causes, the nearest duty physician, Medical Director or attending physician may make the pronouncement of death. Personnel will return the patient record and all forms to the Health Information Management Department, documenting this process in the patient record and obtain a signed Death Certificate from the physician. . ."

Review of the Hospital's Medical Staff Bylaws presented by the hospital as current revealed in part, "Each member of the Medical Staff shall abide by the Medical Staff bylaws and other lawful standards, rules and policies of the Hospital".

Review of Patient #5's medical record revealed the patient was admitted to the hospital on 4/16/2010 at 1440 (2:40 p.m.). Review of Patient #5's Registered Nurse (RN) admission assessment revealed the patient was status post Left Hip Hemiarthroplasty, Dementia, Metastatic CA (cancer), and DM (Diabetes Mellitus). Review of the hospital form titled, "Specified Resuscitation Orders" dated 4/16/2010 revealed the patient was listed as a "full code". The form was signed by Registered Nurse and Licensed Practical Nurse on 4/16/2010 with no documented time stating, "pt (patient) unable to sign, dementia, sedative (at) this time". The form was signed by Physician S3 on 5/03/2010 (16 days after the patient expired). Further review of the medical record for Patient #5 revealed nursing documentation (4/17/2010) at 4:50 a.m. indicating, "went to pts. (Patient's) room to, walked out, to add feeding to bag. Pt. found not breathing + non-responsive. Weak pulse found (at) carotid + then fades. RN in (with) code cart. 911 called. CPR (Cardio Pulmonary Resuscitation) began. No response. EMS (Emergency Medical Services) arrives. Time of death 414 (4:14 a.m.) (Physician S3) notified as well as administration." 0450 (4:50 a.m.) "(Patient #5's son) has returned to bedside."

Review of Patient #5's medical record revealed a "Certificate of Death" with the date of death documented as 4/17/2010. Further review revealed the section of the certificate for "Certifier" where the date and time of death was to be documented as well as the name of the physician and/or coroner was blank.

Review of Patient #5's medical record revealed no documented evidence that the patient had ever been examined by a physician at Specialty Rehabilitation Hospital of Luling to include no documented evidence of a history and physical, no progress notes, and no discharge or death summary.

Review of the entire medical record revealed no documented evidence of who pronounced Patient #5 dead. Review of the entire medical record revealed no copy of the Ambulance Run Sheet. Review of the entire medical record revealed no documented evidence that Patient #5's physician notified the coroner of the patient's death or that the corner indicated the patient's body could be released to the funeral home.

Emergency Medical Service (EMS) A was contacted by the surveyor on 9/28/2010 and a copy of Patient #5's Run Sheet was obtained. Review revealed a call from the hospital was received on 4/17/2010 at 0358 (3:58 a.m.), ambulance was en route at 0358 (3:58 a.m.), ambulance was on scene at 0406 (4:06 a.m.), and a physician's order (Physician S7/ physician on duty for for EMS A) for DNR (Do Not Resuscitate) was obtained at 0408 (4:08 a.m.). Further review revealed Coroner (S8) pronounced Patient #5 dead at 4:14 a.m. (Medical record review for patient #5 revealed no copy of this run sheet.)

During a face to face interview on 9/28/2010 at 10:25 a.m., Director of Nursing S2 confirmed that Physician S7 was not credentialed or privileged at the hospital. S2 confirmed the medical record for Patient #5 contained no documentation by any physician that was credentialed at the hospital- to include no History and Physical, no Progress notes, no notification of the coroner regarding the patient's death, and no Discharge or Death Summary.

During a face to face interview on 9/28/2010 at 11:15 a.m., Physician S3 indicated he had never seen Patient #5 and therefore did not document on the patient. Physician S3 indicated it was his understanding that Patient #5 experienced a Cardiac Arrest during the first 24 hours of his hospital stay and the EMT (Emergency Medical Technicians) that responded provided emergency care, called the code, and pronounced the patient dead. Physician S3 indicated he initiated a death certificate for Patient #5 several days later. Physician S3 indicated he had 24 hours to see patients after they were admitted to the hospital and had not yet seen Patient #5. Physician S3 confirmed that he had not pronounced the patient dead and had not contacted the coroner's office regarding the patient's death.

Review of the hospital policy titled, "Coroner's Cases, N 2.042 (no documented date)" presented by the hospital as their current policy revealed in part, "The physician reports coroners's cases to the coroner. . . The Coroner is to be notified in all cases of death involving the following: . . Deaths without an attending physician within 36 hours prior to the hour of death. . . Any death from natural causes occurring in a hospital under twenty four hours admission, unless seen by a physician in the last thirty six hours. . ."

Based on record review and interview the hospital failed to ensure the Registered Nurse supervise and evaluate the nursing care for each patient by:
1) Failing to ensure that policies/procedures were developed and implemented regarding the need for routine nursing assessments/reassessments of patients who receive insulin medication while hospitalized to ensure that blood glucose readings are maintained at a safe range to assist nursing personnel in providing nursing interventions if required for rapid decline/increases in blood glucose. The failure to have a policy and procedure to direct nursing staff in this area resulted in patient #2 experiencing a severe decline in blood glucose following insulin administration without nursing staff being aware and required the patient to be transferred to another hospital for medical care.
2) Failing to ensure Patient Assessments were performed as needed by: a) failing to have the Registered Nurse assess patients with a significant change in condition for 1 of 1 death records reviewed out of a total sample of 5 (Patient #5). b) failing to re-assess hyperglycemic patients who received insulin to ensure that blood glucose readings returned to a safe range for 1 of 5 sampled patients (#2). Patient #2 was given insulin for severe hyperglycemia (446 milligrams per deciliter Capillary Blood Glucose). The patient's capillary blood glucose was reassessed one time only after receiving 12 units of insulin at bedtime (10:00 p.m. Capillary Blood Glucose of 292) and not re-assessed again until 5:25 a.m. when the patient was found unresponsive with a glucose level of 27. This resulted in the patient having to be transferred to another hospital's ICU (Intensive Care Unit) after the patients blood glucose declined to a critical level of 27 milligrams per deciliter. c) failing to ensure patients's vital signs were assessed prior to the administration of Digoxin and/or Metoprolol for 1 of 5 sampled patients (# 4).
3) Failing to ensure that blood glucometer machines used to determine blood glucose readings for the administration of oral and/or injectable insulin to patients were determined accurate as evidenced by the failure of nursing staff to perform quality controls on the glucometer machines according to manufacturer's recommendations. Solutions used by nursing staff to check for accuracy of the "high" level readings had not been used since 8/23/2010 and the solutions used to detect the accuracy of the "low" level readings had expired.
4) Failing to ensure that nursing staff reported and took immediate action to correct and/or remove glucometers from use when glucometer test results were outside of the expected/acceptable range for the control solutions for 1 of 1 Capillary Blood Glucose Machine in the hospital.
5) Failing to ensure that nursing staff were knowledgeable of the need to use oxygen during resuscitation procedures. This was evident in 1 of 1 death record reviewed out of a total sample of 5 (#5).
6) Failing to ensure the hospital policy titled, "Death of a Patient" was followed relative to pronouncement of death, notification of Medical Examiner, and notification of Louisiana Organ Procurement Agency (LOPA) for 1 of 1 death record reviewed out of a total sample of 5 (#5).
7) failing to ensure patients were weighed as per physician's orders for 1 of 5 sampled patients (#3). Findings:

1)
Review of the hospital's entire policy and procedure manual revealed no documented evidence of a policy directing the nursing care of patient's whose capillary blood glucose levels detected hyperglycemia.

During a face to face interview on 9/28/2010 at 11:15 a.m., Physician S3 indicated he would usually expect nursing staff to treat hyperglycemic patients by repeating a blood sugar in two hours and then again in another two hours if the patient's blood sugar remained high. Physician S3 further indicated he would sometimes instruct nursing staff with a verbal order to repeat the blood glucose levels but was not always consistent with giving followup assessment orders for patients with elevated capillary blood glucose levels.

During a face to face interview on 9/28/2010 at 2:30 p.m., Director of Nursing S2 confirmed the hospital had no policy and procedure directing the nursing care of patients whose capillary blood glucose levels detected hyperglycemia.


2)
2a) Review of Patient #5's medical record revealed the patient was admitted to the hospital on 4/16/2010 at 1440 (2:40 p.m.) with diagnoses that included Status Post Open Reduction Internal Fixation of left hip post fall, Metastatic Prostate Cancer, Dementia, Osteoporosis, and Renal Lesion. Review of Nurses Notes dated 4/17/2010 at 0350 (3:50 a.m.) revealed "went to pts (patients) room to, walked out, to add feeding to bag. Pt. found not breathing (and) non-responsive. Weak pulse found (at) carotid (and) then fades. RN (Registered Nurse) in (with) code cart. 911 called. CPR (Cardiopulmonary Resuscitation) began. No response. EMS (Emergency Medical Services) arrives. Time of death 414. (Physician S3) notified as well as administration." Review of the entire medical record revealed no documented evidence of a Registered Nurse evaluating Patient #5 for a change in condition on the 6 p.m. - 6 a.m. shift of 4/16/2010 through 4/17/2010 prior to the time the patient was found in cardiopulmonary arrest at 3:50 a.m.

During a telephone interview on 9/28/2010 at 1:40 p.m., Registered Nurse (RN) S10 indicated she was the Registered Nurse in charge of the hospital on 4/16/2010 from 6:00 p.m. until 4/17/2010 at 6:00 a.m. RN S10 further indicated that she was aware that LPN (Licensed Practical Nurse) S9 had been concerned about Patient #5 as evidenced by LPN S9 stating that she (S9) didn't like the way the patient looked. S10 indicated she did not recall any specific voiced concerns by S9 other than not liking the way the patient looked. S10 further indicated that LPN S9 had been monitoring the patient (#5) closely all night. RN S10 further indicated that although she (S10) knew LPN S9 had been very concerned about Patient #5 that she (RN S10) had never gone to the patients room to perform a Registered Nurse assessment prior to 3:50 a.m. when she (RN S10) was called into the room because the patient (#5) had coded (experienced a cardio-pulmonary arrest).

2b) Review of Patient #2's medical record revealed the patient was admitted to the hospital on 8/18/2010 with diagnoses that included Status post distal right tibia/fibula fracture with Open Reduction Internal Fixation, Poor Cognition, Hypertension, Diabetes with Neuropathy, Increased Lipids. Review of Patient #2's Discharge Summary revealed the diagnosis of "Uncontrolled diabetes with hypoglycemia and recent fever" was added. Further review revealed in part, " Discharge Disposition: To emergency room. . . Unfortunately she developed a hypoglycemic episode with a blood sugar of 27 at 5:00 a.m., She did receive one amp of Glucagon at 8:30 a.m. blood sugar was 97, however, patient was sent to emergency room for further evaluation. . ."

Record review revealed the initial physician's order for Routine Scheduled Insulin (Long Acting Insulin) for Patient #2 was dated 8/18/2010 at 5:25 p.m. for Lantus 10 units subcutaneously every day.
Review of Patient #2's medical record revealed physician's orders for Routine Administered Insulin (Long Acting Insulin) was steadily increased during the patient's (#2) hospital stay as follows:
8/19/2010 at 11:38 a.m. physician's orders indicated Lantus (Insulin) was increased to 10 units every 12 hours
8/20/2010 at 11:47 a.m. physician's orders indicated Lantus (Insulin) was increased to 15 units every 12 hours.
8/23/2010 at 11:50 a.m. physician's orders indicated Lantus (Insulin) was increased to 18 units every 12 hours.
8/24/2010 at 11:20 a.m. physician's orders indicated Lantus (Insulin) was increased to 22 units every 12 hours.
8/27/2010 at 4:33 p.m. physician's orders indicated Lantus (Insulin) was increased to 26 units every 12 hours.

Review of Patient #2's medical record revealed the patient was ordered Sliding Scale Insulin Subcutaneously upon admission on 8/18/2010 at 5:20 p.m. as follows:
151 - 173 = 2 units, 174- 203 = 3 units, 204 - 233 = 4 units, 234 - 263 = 5 units, 264- 293 = 6 units, 294- 323 = 7 units, 324 - 353 = 8 units, 354 - 383 = 9 units, 384 - 413 = 10 units, 414 - 443 = 11 units, 444 - 450 = 12 units, and 450 and greater call MD (Medical Doctor). Initiate Hypoglycemic Protocol if BS (blood sugar) < 60 milligrams/ deciliter = retest and notify Medical Doctor. If symptomatic with decreased level of consciousness, give 1 amp (ampule) (1 milligram/milliliter) of Glucagon.

Review of the hospital policy titled, "Policy: Definitions of Critical Values (no documented date)" revealed in part, "For procedures performed for Specialty Hospital, the following values are considered critical values: Glucose: Low/ Less than 40 milligrams per deciliter, High/ greater than 400 milligrams per deciliter. . . These critical values may be laboratory, arterial blood gases values, or radiological results which are considered life threatening unless something is done promptly and/or for which some corrective action could be taken."

Review of Patient #2's medical record revealed the patient was documented as having Critical Capillary Blood Glucose (CBG) levels greater than 400 as follows:

-8/18/2010 at 1630 (4:30 p.m.): Patient #2's CBG was documented as 431 and #2 was treated with 11 units of Regular Insulin per sliding scale.
Review of Physician's orders for Patient #2 dated 8/18/2010 at 2110 (9:10 p.m.) revealed an order to give 12 units of Novolog Insulin Subcutaneously now and recheck blood sugar at midnight. Cover Blood Sugar using Sliding Scale. Recheck again at 3:00 a.m.
Review of Patient #2's entire medical record revealed no documented evidence that Patient #2 had her CBG level repeated at midnight or at 3:00 a.m. as ordered by the patient's physician. This finding was confirmed by the Director of Nursing.
Review of Patient #2's entire medical record revealed the next assessment of CBG for Patient #2 did not occur until 8/19/2010 at 7:30 a.m. (10 hours and 20 minutes after the 9:10 p.m. Critical CBG).

-8/19/2010 at 1130 (11:30 p.m.): Patient #2's CBG was documented as 498 and #2 was treated with 12 units of Regular Insulin per sliding scale.
Review of Patient #2's entire medical record revealed no documented evidence of a follow up assessment of Patient #2's Critical Level CBG until the next scheduled accucheck on 8/19/2010 at 1650 (4:50 p.m./ 5 hours and 20 minutes later).

-8/19/2010 at 1650 (4:50 p.m.): Patient #2's CBG was documented as 504 and #2 was treated with 12 units of Regular Insulin per sliding scale.
Review of Patient #2's entire medical record revealed no documented evidence of a follow up assessment of Patient #2's Critical Level CBG until the next scheduled accucheck on 8/19/2010 at 2000 (8:00 p.m./3 hours and 10 minutes later.)

-8/27/2010 at 2000 (8:00 p.m.): Patient #2's CBG was documented as 446 and #2 was treated with 12 units of Regular Insulin.
Review of Patient #2's medical record revealed a follow up CBG was documented on Patient #2 at 2200 (10:00 p.m.) which revealed a level of 292 (a drop of 154 in 2 hours). Review of the entire medical record revealed no further assessment of Patient #2's CBG until the patient was found to be unresponsive to tactile stimuli at 5:25 a.m. on 8/28/2010 (5 hours and 25 minutes after the last documented CBG).

Review of Patient #2's Nurses Notes/Narrative dated 8/28/2010 at 5:25 a.m. revealed in part, "upon entering room, calling pts (patient's) name, 0 (no) response (with) tactile stimuli (and) pts. skin feet, clammy . . . there was response (with) groaning to sternal rub but blinking eyes only, 0 (no) verbal response. . . 167/90 (blood pressure) - 80 (heart rate) - 16 (respirations) -96.0 (temperature) . 92% (oxygen saturation) RA (room air) sats (saturation); upon blood glucose check pts. (accucheck) (at) 27. 1 amp (ampule) glucagon given IM (Intramuscular) to L (left) UA (upper arm) (without) diff. (difficulty). MD (Doctor) notified (and) awaiting return call. will continue to closely monitor." 0526 (5:26 a.m.) physician returned call. 0535 (5:35 a.m.) ". . . blood sugar (increased) to 97. . continues to have involuntary twitching of BUE (bilateral upper extremities) and R (right) face area. . . instructed to call 911 for EMT (Emergency Medical Team). . ." 0612 (6:12 a.m.) "Blood sugar (at) 104 (patient transferred to Hospital B)."

During a face to face interview on 9/28/2010 at 11:15 a.m., Physician S3 (Medical Director) indicated Patient #2 had been running elevated CBG (Capillary Blood Glucose) levels for most of her stay. S3 further indicated the patient (#2) appeared to have a Urinary Tract Infection which would possibly have increased her glucose levels. S3 indicated he had started #2 on Cipro 500 milligrams by mouth twice a day on 8/09/2010 (confirmed with record review). S3 further indicated he (S3) had steadily increased Patient #2's Lantus during her (#2) hospital stay due to a pattern of elevated CBG levels. S3 indicated that he would typically order nursing staff to repeat a blood glucose level in 2 hours after treating a critical CBG level and then order another repeat two hours after that. S3 further indicated he did not always verbalize that expectation. Physician S3 indicated it would be difficult to tell why Patient #2's CBG dropped to 27 on the morning of 8/27/2010 at 5:25 a.m. Physician S3 indicated the patient may have eaten or drank a sugar substance around the time of her 8:00 p.m. accucheck which would have given her a rapid increase in blood sugar followed by a rapid decrease in blood sugar. Physician S3 further indicated that in hindsight it may have been helpful if he (S3) had adjusted her (#2's) sliding scale insulin as he (S3) went up on her Lantus Insulin; however, at the time there had been no indication of a need to change the Sliding Scale.

During a face to face interview on 9/28/2010 at 10:00 a.m., Registered Nurse (RN) S11 indicated she had been the nurse caring for Patient #2 on the night shift of 8/27/2010 through the morning of 8/28/2010. RN S11 further indicated that although she typically would not have repeated a CBG level after treating a patient with insulin for sliding scale when she worked day shift, that she did repeat the CBG on Patient #2 at 10:00 p.m. after treating a 446 CBG with 12 units of insulin at 8:00 p.m. RN S11 indicated her rationale was that patients would be very active during the day and she would have been able to visualize symptoms of hypoglycemia during the day hours; however at night the patient would be sleeping and she would not be able to notice changes indicating hypoglycemia in the patient. S11 indicated Patient #2 had received a good bit of insulin (12 units) at 8:00 p.m. and she (S11) felt it necessary to recheck the CBG at 10:00 p.m. S11 indicated she (S11) had not felt it necessary to repeat it again after seeing the level was 292 at 10:00 p.m.
The Director of Nursing was present during this interview and confirmed the hospital had no policy for treating hyperglycemia per sliding scale to include follow up assessments post insulin administration for critical value blood glucose levels.

During a telephone interview on 9/30/2010 at 4:15 p.m., Physician S15 (Critical Care Medicine from Hospital A) indicated Patient #2 had been admitted to the Intensive Care Unit at Hospital A on 8/28/2010 in an obtunded state due to a Hypoglycemic incident. S15 indicated Patient #2 remained in an altered mental state for several days after admission to the hospital before she began to improve. S15 indicated the Consulting Neurologist diagnosed the Patient as having Hypoglycemic Encephalopathy.

2c) Review of Patient #4's medical record revealed the patient was admitted to the hospital on 9/03/2010 and remained in the hospital at the time of the survey. Review of Patient #4's physician's orders dated 9/03/2010 at 4:00 p.m. revealed orders that included Digoxin 0.25 milligrams by mouth daily and Metoprolol 50 milligrams by mouth two times per day. Review of Patient #4's Medication Administration Record revealed Patient #4 was administered Digoxin with no documented evidence of taking an apical or radial pulse prior to the administration (as indicated in Hospital Drug Reference Handout indicating "Before giving drug, take apical-radial pulse for 1 minute. Excessively slow pulse, 60 beats per minute or less, may be a sign of Digitalis toxicity) on 9/10/2010, 9/14/2010 and 9/15/2010 at 8:00 a.m. Further review revealed Patient #4 was administered Metoprolol with no documented evidence of taking the patient's apical pulse prior to the administration (as indicated in Hospital Drug Reference Handouts indicating "Always check patient's apical pulse rate before giving drug and withhold drug and call prescriber if pulse less than 60".) on 9/06/2010 at 8:00 p.m., 9/07/2010 at 8:00 p.m., 9/08/2010 at 8:00 p.m., 9/09/2010 at 8:00 p.m., 9/10/2010 at 8:00 a.m. and 8:00 p.m., 9/11/2010 at 8:00 p.m., 9/13/2010 at 8:00 a.m. and 8:00 p.m., and 9/15/2010 at 8:00 p.m.

This finding was confirmed by the Director of Nursing on 9/30/2010 at 3:00 p.m. who further indicated nursing staff should obtain and record apical pulses as per drug reference prior to the administration of Digoxin and Metoprolol.

Review of Drug Reference Handouts provided by the Director of Nursing as current revealed the following:
Metoprolol Succinate/ Metoprolol Tartrate: Nursing Considerations- Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately. . . Monitor blood pressure frequently; drug masks common signs and symptoms of shock.
Lanoxin/ Digoxin:Before giving drug, take apical-radial pulse for 1 minute. Record and notify prescriber of significant changes. . . Excessively slow pulse rate (60 beats/minute or less) may be a sign of digitalis toxicity. Withhold drug and notify prescriber.

3)
Observations on 9/27/2010 at 10:30 a.m. revealed the only device for testing Capillary Blood Glucose in the hospital (McKesson True Track Glucometer) to have no High Control Testing Solution and Low Testing Solution of Level I to have expired in 8/31/2010 (expired for 28 days).

Review of the hospital's Glucometer Quality Control Log revealed the hospital was out of High Control Solution since 8/23/2010 (35 days).

During a face to face interview on 9/27/2010 at 11:05 a.m., Materials Management Staff S6 and Director of Nursing S2 both indicated they did not know that the only testing solution for Low Controls in the hospital had expired on 8/31/2010 and that there was no High Control Solution available (out of stock). S2 indicated Quality Control Testing of the Capillary Blood Glucose machine had been delegated to Certified Nursing Staff (policy indicated it was the responsibility of the Registered Nurses and/or Licensed Practical Nurses) and she (S2) had failed to check behind them to determine if Quality Controls were being performed consistently and accurately. S2 indicated there would be no way to know if any glucose levels had been accurate using the Capillary Blood Glucose machine since 8/23/2010.

Review of the hospital policy titled, "Glucometer Quality Control Testing, N 2.060 date 07/10" presented by the hospital as their current policy revealed in part, "Registered Nurses and Licensed Practical Nurse are the staff members identified to perform quality control. . . always check expiration date on the test strips and control solutions. . . Throw away expired test strips and solutions."

4)
Review of the hospital's Glucometer Strips Bottle revealed the grid for testing solutions to include Level 0 (88 - 118), Level 1 (183 - 247), and Level 2 (368-498).

Review of the hospital's "Glucometer Quality Control Log" for the year 2010 revealed in part, "Low Control 5/10/2010 was 255 (7 above acceptable parameters), Low Control on 6/04/2010 was 248 (1 above acceptable parameters), 7/05/2010 revealed no quality testing performed, 7/08/2010 revealed no quality testing was performed, 7/13/2010 was 249 (2 above acceptable parameters), 7/14/2010 was 265 (18 above acceptable parameters), 7/25/2010 revealed no quality testing was performed, 7/30/2010 revealed no quality testing was performed, 8/30/2010 was 253 (6 above acceptable parameters), 9/12/2010 revealed no quality testing was performed, 9/13/2010 revealed no quality testing was performed,
9/16/2010 revealed no quality testing was performed, 9/19/2010 revealed no quality testing was performed, 9/20/2010 revealed no quality testing was performed, 9/21/2010 revealed no quality testing was performed, 9/24/2010 revealed no quality testing was performed, 9/25/2010 revealed no quality testing was performed, 9/26/2010 revealed no quality testing was performed. Further review revealed no documented evidence of testing for high Controls since 8/23/2010. Review of the entire Glucometer Quality Control Log revealed no documented evidence that the machine was rechecked or that the nurse in charge was notified for readings that were outside the acceptable ranges/parameters.

During a face to face interview on 9/28/2010 at 8:45 a.m., Certified Nursing Assistant S13 indicated there were times when she had been too busy to get around to testing the controls on the Capillary Glucose Monitoring Device. S13 indicated she had never known the machine to be out of range.

During a face to face interview on 9/28/2010 at 11:05 a.m., Certified Nursing Assistant S14 indicated she was one of the staff that performed quality controls on the capillary glucose machine/device. S14 further indicated she knew to use the solution and log the number of the reading. S14 further indicated she did not know what the numbers meant and did not know whether the readings were in range or not.

During a face to face interview on 9/28/2010 at 11:05 a.m., Director of Nursing S2 (after reviewing the Glucometer Quality Control Log) confirmed there was no documented evidence that staff were noting readings that were outside the acceptable parameters for the machine. S2 indicated she would expect staff to handle out of range readings as per package inserts.

Review of the Package Insert for "McKesson Truetrack" revealed in part, "Match Code in Display with Code on Test Strip vial label being used. . . Compare result to Control range printed on Test Strip vial label: If result is in range, System can be used for testing blood. If result does not fall within range, repeat test using a new Test Strip. Caution! If Control Test result continues to be outside range, system should not be used for testing blood."

Review of the hospital policy titled, "Glucometer Quality Control Testing, N 2.060 date 07/10" presented by the hospital as their current policy revealed in part, "Registered Nurses and Licensed Practical Nurse are the staff members identified to perform quality control. . . always check expiration date on the test strips and control solutions. . . Throw away expired test strips and solutions. . . If result is within range, system can be used for testing blood. If result does not fall within range, repeat test using a new Test Strip. If Control Test result continues to be out of range, System should not be used for testing."

5)
Review of Patient #5's medical record revealed the patient was admitted to the hospital on 4/16/2010 at 1440 (2:40 p.m.) with diagnoses that included Status Post Open Reduction Internal Fixation of left hip post fall, Metastatic Prostate Cancer, Dementia, Osteoporosis, and Renal Lesion. Review of Nurses Notes dated 4/17/2010 at 0350 (3:50 a.m.) revealed "went to pts (patients) room to, walked out, to add feeding to bag. Pt. found not breathing (and) non-responsive. Weak pulse found (at) carotid (and) then fades. RN (Registered Nurse) in (with) code cart. 911 called. CPR (Cardiopulmonary Resuscitation) began. No response. EMS (Emergency Medical Services) arrives. Time of death 414. (Physician S3) notified as well as administration." Review of the entire medical record revealed no documented evidence that oxygen was used during the resuscitation of Patient #5.

During a telephone interview on 9/28/2010 at 1:40 p.m., Registered Nurse S10 indicated she responded to the call for a code on Patient #5 when LPN (Licensed Practical Nurse) S9 called out for help on 4/17/2010 at 0350 (3:50 a.m.). RN S10 further indicated she brought the crash cart in and ventilated the patient using an ambu to room air.

During a face to face interview on 9/28/2010 at 2:30 p.m., Director of Nursing S2 indicated nursing staff should use oxygen when ventilating patients during cardiopulmonary resuscitation as required by hospital policy. S2 further indicated there is an oxygen tank attached to the code cart so there would be no reason why it should not have been connected during the code on patient #5 on 4/17/2010.

Review of the hospital policy titled, "Cardiopulmonary Resuscitation Protocol N 2.050 (no documented date)" presented by the hospital as their current policy revealed in part, "Remove O2 (oxygen) setup from crash cart and connect to Ambu bag at 8 - 10 L/Min (liters per minute)."

6)
Review of the hospital policy titled, "Death of a Patient, Rev (6/10)" presented by the hospital as their current policy revealed in part, "When a patient death occurs from natural causes, the nearest duty physician, Medical Director or attending physician may make the pronouncement of death. . . When a death occurs from unusual causes or circumstance, personnel will immediately notify the duty physician, Medical Director, attending physician, Administrator, Director of Nursing. The Administrator will ensure that the local medical Examiner is notified, or if not available, the Sheriff's Department and ask for special instructions. . . In the event of a patient death, nursing personnel will notify the Louisiana Organ Procurement Agency. . ."

Review of the hospital's policy titled, "Coroner's Cases N 2.042 (no documented date) revealed in part, "The physician reports coroner's cases to the coroner. The Coroner is to be notified in all cases of death involving the following: 5) Deaths without an attending physician within 36 hours prior to the hour of death. . . Any death from natural causes occurring in a hospital under twenty-four (24) hours admission, unless seen by a physician in the last thirty-six (36) hours. . . If the Coroner is notified for the above reasons, the Death Certificate is completed by the Coroner, not the attending physician. The Coroner will authorize the removal of the body to a place designated by him/her."

Review of Patient #5's medical record revealed the patient died at the hospital on 4/17/2010 at 4:14 a.m. Further review of the entire medical record revealed no documented evidence that any physician from the hospital had examined the patient from the time of his admission on 4/16/2010 at 1440 (2:40 p.m.) until the time of his death on 4/17/2010 at 4:14 a.m. Review of the entire medical record revealed no documented evidence to indicate the name of the physician and/or coroner that pronounced the patient dead. Review of the entire medical record revealed no documented evidence of a run report by Ambulance A. Review of the entire medical record revealed no documented evidence that LOPA (Louisiana Organ Procurement Agency) was contacted. Review of the entire medical record revealed no documented evidence that a coroner or physician gave an order allowing the body to be released to the funeral home.

Review of the Ambulance Run Sheet (EMS A) for Patient #5 dated 4/17/2010 (made available to the surveyor per request to the Ambulance Service/ no copy available on Patient #5's medical record) revealed a call was made to Ambulance at 3:58 a.m., the ambulance was enroute at 3:58 a.m. and arrived on the scene at 4:06 a.m. Further review revealed the patient showed asystole in three leads at 4:08 a.m. and "EMS (Emergency Medical Service) A" Physician S7 ordered DNR (Do Not Resuscitate) with no documentation of the time. Further review revealed Coroner S8 pronounced the patient dead at 4:14 a.m. Review of the entire Run Sheet revealed no documented evidence of the coroner indicating it was okay for the patient's body to be released to the funeral home.

During a telephone interview on 9/30/2010 at 9:30 a.m., Director of "EMS A" S12 indicated that when a hospital or nursing home calls 911; it is a given that the hospital has given over control of the medical emergency to the Department of Emergency Medical Services. S12 further indicated when they (EMS A) arrive at the scene, the paramedics make an assessment of the emergency and obtain a history from the facility. S12 indicated EMS staff then call their commanding physician and receive orders based on their (EMS staff's) assessment. S12 indicated in the case of Patient #5; it was documented that the patient had metastatic cancer, had last been seen by hospital staff 10 minutes prior to EMS being called, CPR (Cardio-pulmonary resuscitation) had been in progress for 8 minutes, and the patient had asystole in 3 leads (based on EMS assessment at the time of arrival). S12 indicated their physician (S7) had made Patient #5 a DNR based on the patient's history and assessment by the paramedics. S12 further indicated that because the patient had been in the hospital less than 24 hours, the case would automatically be a coroner's case and that is why his staff called the coroner and had the patient pronounced dead at 4:14 a.m. S12 indicated the paramedics would then be placed back on available status for other emergency calls. S12 indicated he did not know why there was no copy of the Ambulance Run sheet left with the hospital.

During a face to face interview on 9/28/2010 at 10:25 a.m. with Licensed Practical Nurse S9 and a telephone interview on 9/28/2010 at 1:40 p.m. with Registered Nurse S10, both indicated they had been unfamiliar with the protocol for handling deaths at the hospital and had made a phone call to the former Director of Nursing for instruction. Both indicated they had proceeded as instructed. Both indicated they had not notified LOPA and did not know the name and title of who had pronounced the patient (#5) dead. Both indicated Patient #5 had been pronounced dead by someone that the paramedics had been speaking with; LPN S9 thought it was a physician and RN S10 thought it was a coroner, but neither had requested the name of the person declaring the patient dead. LPN S9 confirmed there was no documented evidence in the medical record for Patient #5 that the coroner and/or physician had given an order indicating the body could be released to the funeral home. LPN S9 confirmed there was no copy of the Ambulance Report in the Medical Record.

During a face to face interview on 9/28/2010 at 2:30 p.m., Director of Nursing S2 indicated she had not been working at the hospital during April 4/2010. S2 further indicated that she could not be sure what instructions were provided to LPN S9 or RN S10 in regards to how to handle the death of Patient #5 by the former Director of Nursing. S2 indicated the policy titled, "Death of a Patient" was last revised "6/10" and she was not sure what the prior policy contained. S2 confirmed that a physician that had no privileges at the hospital would not be able to pronounce a patient dead, that LOPA should be notified of all deaths at the hospital, and that documentation should have been clear regarding who pronounced Patient #5 dead. S2 indicated she was not familiar with Coroner's cases; however, staff should have followed hospital policy.


7)
Review of Patient #3's medical record revealed the patient was admitted to the hospital on 9/23/2010 with physician's orders documented at 12:45 p.m. that included an order for "weight on admit, daily". Review of the entire medical record revealed no documented evidence that patient was ever weighed. The dietician's assessment dated 9/25/2010 at 1830 (6:30 p.m.) was based on an estimated weight. Review of Patient #3's Weekly Graphic Sheet revealed documentation dated 9/26/2010 at 7:00 a.m. indicating "unable to weigh".

During a face to face interview on 9/28/2010 at 8:45 a.m., CNA (Certified Nursing Assistant) S13 indicated there was no bed scale available at the hospital to weigh Patient #3; however, they would have been able to weigh the patient

Based on record review and interview the hospital failed to ensure patient care plans (treatment plans) were updated to include diabetes and/or sliding scale insulin for 4 of 5 diabetic patients reviewed (#2, #3, #4, #5). Findings:

Review of the following patient's records revealed the patients were diabetic and also on sliding scale insulin as per physician's orders #2, #3, #4, #5.

Patient #2 was admitted to the hospital on 8/18/2010 with diagnoses of Status Post fracture of the right distal tibia and fibula with Open Reduction Internal Fixation of the right tibia, hypertension, and diabetes. Sliding Scale insulin was ordered by the patient's physician on 8/18/2010 at 5:20 p.m. Review of Patient #2's entire medical record revealed no documented evidence that the nursing care plan was updated to include sliding scale insulin administration to include nursing interventions for hypoglycemia/hyperglycemia.

Patient #3 was admitted to the hospital on 9/23/2010 with diagnoses of Inflammatory Plexopathy and Diabetes with neuropathy. Sliding Scale insulin was ordered by the patient's physician on 9/24/2010 at 12:45 p.m.. Review of Patient #3's entire medical record revealed no documented evidence that the nursing care plan was updated to include sliding scale insulin administration to include nursing interventions for hypoglycemia/hyperglycemia.

Patient #4 was admitted to the hospital on 9/03/2010 with diagnoses of Respiratory Failure, Pneumonia, Sepsis, Chronic Obstructive Pulmonary Disease, and Diabetes with Neuropathy. Sliding Scale insulin was ordered by the patient's physician on 9/03/2010 at 4:00 p.m.. Review of Patient #4's entire medical record revealed no documented evidence that the nursing care plan was updated to include sliding scale insulin administration to include nursing interventions for hypoglycemia/hyperglycemia.

Patient #5 was admitted to the hospital on 4/16/2010 with diagnoses of Left Hip Hemiarthroplasty, Dementia, Metastatic Cancer, and Diabetes. Sliding Scale insulin was ordered by the patient's physician on 4/16/2010 at 12:00 p.m.. Review of Patient #5's entire medical record revealed no documented evidence that the nursing care plan was updated to include sliding scale insulin administration to include nursing interventions for hypoglycemia/hyperglycemia.

During a face to face interview on 9/28/2010 at 2:30 p.m., Director of Nursing S2 confirmed the nursing care plans of Patients #2, #3, #4, and #5 did not include a plan of care to address sliding scale insulin with nursing interventions for patients with hypoglycemia/hyperglycemia.
S2 further indicated the nursing care plans of these patients should have included sliding scale insulin and nursing interventions for hypo/hyperglycemia.

Based on record review, and interview the hospital failed to ensure the Registered Nurse did not delegate to unlicensed nursing personnel capillary blood glucose testing on patients that required sliding scale insulin based on CBG (Capillary Blood Glucose) results. This is in violation of the Louisiana State Board of Nursing Requirements. Findings:

Review of the hospital policy titled, "Capillary Blood Glucose Testing, N 2.020 (no documented date)" presented by the hospital as their current policy revealed in part, "Capillary blood glucose testing will be performed at intervals prescribed by the physician. Purpose: to provide all SRH (Specialty Rehabilitation Hospital) patients with quality nursing service in the treatment of diabetes." Review of the entire policy revealed no documented evidence of what discipline of staff were responsible for performing Capillary Blood Glucose testing.

Review of the hospital policy titled, "Glucometer Quality Control Testing, N 2.060 (dated 7/10)" presented by the hospital as their current policy revealed in part, "Quality Control on the glucometer will be performed to ensure accurate and reliable testing using he high and low level control solutions. Quality Control testing will be performed nightly by the nursing staff. . . Registered Nurses and Licensed Practical Nurses are the staff members identified to perform quality control."

Review of a letter dated 2/20/1995 from the Louisiana Board of Nursing revealed in part, "Your request for an opinion of the Board of Nursing regarding a registered nurse delegating to ancillary (unlicensed) personnel the performance of capillary blood glucose monitoring (Glucometer or Accucheck) was presented to the Board at it's February 15, 1995 meeting. The Nursing Practice Committee studied the issue, and at it's January 9,1995 meeting, the committee formulated a recommendation to the Board of Nursing. On February 15, 1995 the committee presented it's recommendation to the Board, and after due deliberation, the board adopted the following opinion. . . . Unlicensed personnel may not perform one-touch monitoring when insulin to scale is ordered."

During a face to face interview on 9/27/2010 at 10:40 a.m., Licensed Practical Nurse S5 indicated the hospital utilizes their Certified Nursing Assistants to perform Accucheck on all patients with orders for Accucheck and/or sliding scale insulin. This finding was confirmed by Director of Nursing (DON) S2 on 9/27/2010 at 11:00 a.m. who further indicated Registered Nurses (RN) and Licensed Practical Nurses (LPN) at the hospital have delegated Accucheck monitoring to non-licensed Certified Nursing Assistants. DON S2 further indicated she did not know that the Louisiana State Board of Nursing did not support delegation of Accucheck on patients with sliding scale insulin to non-licensed personal. DON S2 confirmed that Patients #2, #3, #4, and #5 were all patients on sliding scale insulins. DON S2 indicated Patients #2, #3, #4, and #5 would have had their Accucheck performed by Certified Nursing Assistants (CNA). S2 further indicated the CNA that performed the test would not have documented their name or initials in the medical records of the patients because the LPN or RN that transcribed the results would have placed their initials on the Diabetic Flow sheet rather than the CNA performing the test. DON S2 confirmed that although the hospital policy titled "Glucometer Quality Control Testing, N 2.060" indicated nursing staff were to perform accuchecks, it had been the practice of the hospital to have the Certified Nursing Assistants perform the test.

Based on record review and interview the hospital failed to ensure the medical record was accurately written for 1 of 5 sampled patients (Patient #5). Findings:

Patient #5 was admitted to the hospital on 4/16/2010 with diagnoses of Left Hip Hemiarthroplasty, Dementia, Metastatic Cancer, and Diabetes. Sliding Scale insulin was ordered by the patient's physician on 4/16/2010 at 12:00 p.m.. Review of physician's sliding scale order revealed in part, "Insulin Reg (Regular) per sliding scale." Further review revealed standing orders for sliding scale to include 174 - 203 = 3 units. Review revealed no check mark next to the standing order for sliding scale.

Review of Patient #5's "Diabetic Flowsheet" revealed in part, "4/16/10, 2000 (8:00 p.m.) Results 179, Coverage Amounts 16 units". Review of Patient #5's "Medication/Treatment Record" revealed in part, "4/16, 2000 (8:00 p.m.) 3 units" (same date and time that the patient was documented as receiving 16 units on the Diabetic Flowsheet).

During a face to face interview on 9/28/2010 at 10:25 a.m., Licensed Practical Nurse S9 confirmed that she had documented giving Patient #5, 3 (three) units of insulin in one area of the chart and 16 (sixteen) units of insulin in another area of the chart for the date of 4/16/2010 at 2000 (8:00 p.m.). S9 further indicated she would have charted on the Medication Administration Record first and that would be the most accurate documentation. S9 indicated she did not know why she would have documented 16 units on Patient #5's Diabetic Flow Sheet; however, she doubted that it would be accurate. LPN S9 indicated there had been no assessment of Patient #5's Accucheck at the time of his arrest.

Based on record review and interview the hospital failed to ensure Louisiana Organ Procurement Agency (LOPA) was notified of a patient death for 1 of 1 death reviewed (Patient #5). Findings:

Review of Patient #5's medical record revealed the patient was admitted to the hospital on 4/16/2010 at 1440 (2:40 p.m.). Review of the medical record for Patient #5 revealed nursing documentation (4/17/2010) at 4:50 a.m. indicating, "went to pts. (Patient's) room to, walked out, to add feeding to bag. Pt. found not breathing + non-responsive. Weak pulse found (at) carotid + then fades. RN in (with) code cart. 911 called. CPR (Cardio Pulmonary Resuscitation) began. No response. EMS (Emergency Medical Services) arrives. Time of death 414 (4:14 a.m.) (Physician S3) notified as well as administration." 0450 (4:50 a.m.) "(Patient #5's son) has returned to bedside."

Review of Patient #5's entire medical record revealed no documented evidence that LOPA had been contacted regarding the patient's death.

Review of the hospital policy titled, "Organ and Tissue Donation, N 1.012" presented by the hospital as their current policy revealed in part, "If a patient dies while at SRH (Specialty Rehabilitation Hospital), the RN (Registered Nurse) on duty will notify the Louisiana Organ procurement Agency (LOPA). . . "

During a face to face interview on 9/28/2010 at 10:25 a.m., LPN (Licensed Practical Nurse) S9 indicated there had been no attempt by herself or the Registered Nurse on duty to contact LOPA in regards to the death of Patient #5.

During a telephone interview on 9/28/2010 at 1:40 p.m., Registered Nurse S10 indicated she was the Registered Nurse in charge on the night of 4/17/2010 when Patient #5 died. S10 further indicated she had made no attempt to contact LOPA to notify them of the patient's death.

During a face to face interview on 9/28/2010 at 1:40 p.m., Director of Nursing S2 confirmed there was no documented evidence in the entire medical record for Patient #5 that LOPA had been contacted. S2 further indicated the hospital policy regarding notification of LOPA of patient's deaths should have been followed.

Based on record review and interview the hospital failed to ensure problem prone areas were identified through Quality Assurance for the use of Performance Improvement as evidenced by failing to identify and implement corrective action regarding:
1) Hospital's failure to ensure Quality Control Checks were properly done on the hospital's only Capillary Blood Glucose Machine.
2) Hospital's failure to ensure a patient's death that occurred within the first 24 hours was investigated resulting in failure to identify conflicting information regarding the amount of insulin the patient received, failure to identify who pronounced the patient dead, failure to notify the coroner and/or document the name and time of coroner notification, and failure to notify LOPA of a patient's death for 1 of 1 death reviewed (#5).
3) Hospital's failure to ensure review of Patient Care Plans identified nursing staff's failure to update care plans to include Sliding Scale Insulin with a plan of care for nursing interventions in relation to hypoglycemia and hyperglycemia.
4) Hospital's failure to ensure the Registered Nurse did not delegate capillary blood glucose testing to unlicensed personnel for patients that were on insulin to be administered by a sliding scale based on the results of the capillary blood glucose testing. This is in violation of the Louisiana State Board of Nursing Requirements.
5) Hospital's failure to identify through review of policies that no policy and procedure was in place regarding the assessment/re-assessment of patients receiving insulin to ensure that blood glucose readings were maintained at a safe range.
6) Hospital's failure to identify failure of Nursing Staff to assess and/or re-assess patients with significant change in conditions or patients with Critical Capillary Blood Glucose levels.
Findings:

1)
Observations on 9/27/2010 at 10:30 a.m. revealed the only device for testing Capillary Blood Glucose in the hospital (McKesson True Track Glucometer) to have no High Control Testing Solution and Low Testing Solution of Level I to have expired in 8/31/2010 (expired for 28 days). Review of the hospital's Glucometer Quality Control Log revealed the hospital was out of High Control Solution since 8/23/2010 (35 days).

During a face to face interview on 9/27/2010 at 11:05 a.m., Director of Nursing S2 indicated she did not know that the only testing solution for Low Controls in the hospital had expired on 8/31/2010 and that there was no High Control Solution available (out of stock). S2 indicated Quality Control Testing of the Capillary Blood Glucose machine had been delegated to Certified Nursing Staff and she (S2) had failed to check behind them to determine if Quality Controls were being performed consistently and accurately. S2 indicated there would be no way to know if any glucose levels had been accurate using the Capillary Blood Glucose machine since 8/23/2010.

Review of the hospital's Glucometer Strips Bottle revealed the grid for testing solutions to include Level 0 (88 - 118), Level 1 (183 - 247), and Level 2 (368-498).

Review of the hospital's "Glucometer Quality Control Log" for the year 2010 revealed in part, "Low Control 5/10/2010 was 255 (7 above acceptable parameters), Low Control on 6/04/2010 was 248 (1 above acceptable parameters), 7/05/2010 revealed no quality testing performed, 7/08/2010 revealed no quality testing was performed, 7/13/2010 was 249 (2 above acceptable parameters), 7/14/2010 was 265 (18 above acceptable parameters), 7/25/2010 revealed no quality testing was performed, 7/30/2010 revealed no quality testing was performed, 8/30/2010 was 253 (6 above acceptable parameters), 9/12/2010 revealed no quality testing was performed, 9/13/2010 revealed no quality testing was performed,
9/16/2010 revealed no quality testing was performed, 9/19/2010 revealed no quality testing was performed, 9/20/2010 revealed no quality testing was performed, 9/21/2010 revealed no quality testing was performed, 9/24/2010 revealed no quality testing was performed, 9/25/2010 revealed no quality testing was performed, 9/26/2010 revealed no quality testing was performed. Further review revealed no documented evidence of testing for high Controls since 8/23/2010. Review of the entire Glucometer Quality Control Log revealed no documented evidence that the machine was rechecked or that the nurse in charge was notified for readings that were outside the acceptable ranges/parameters.

Review of Quality Control Meeting Minutes revealed no documented evidence of identifying Quality Control testing of the Accucheck Machines as a problem prone area in need of a corrective action plan.

During a face to face interview on 9/28/2010 at 11:05 a.m., Director of Nursing S2 (after reviewing the Glucometer Quality Control Log) confirmed there was no documented evidence that staff were noting readings that were outside the acceptable parameters for the machine or that corrective measures had been taken.


During a face to face interview on 9/30/2010 at 10:00 a.m., QAPI (Quality Assurance Performance Improvement) Director LPN (Licensed Practical Nurse) S16 confirmed there had been no identification of errors in performing Quality Controls on the Capillary Blood Glucose machine in the hospital and therefore no corrective action had been implemented.

2)
Review of Patient #5's medical record revealed the patient was admitted to the hospital on 4/16/2010 at 1440 (2:40 p.m.) with diagnoses that included Status Post Open Reduction Internal Fixation of left hip post fall, Metastatic Prostate Cancer, Dementia, Osteoporosis, and Renal Lesion (Full Code Status). Further review revealed the patient was on sliding scale insulin per physician's orders 4/16/2010 at 12:20 p.m. Review of Patient #5's Medication Treatment Record revealed the patient received 3 units of Humulin Regular Insulin per sliding scale at 2000 (8:00 p.m.) on 4/16/2010 for a capillary blood glucose reading of 179. Review of Patient #5's Diabetic Flow sheet revealed the patient's (capillary blood glucose) result was 179 at 2000 on 4/16/2010 and "Coverage Amount" was "16" units. Review of the hospital's standing orders for patients receiving sliding scale insulin revealed that a capillary glucose level of 174 - 203 would require 3 units of Regular Insulin Subcutaneously. Review of Nurses Notes dated 4/17/2010 at 0350 (3:50 a.m.) revealed "went to pts (patients) room to, walked out, to add feeding to bag. Pt. found not breathing (and) non-responsive. Weak pulse found (at) carotid (and) then fades. RN (Registered Nurse) in (with) code cart. 911 called. CPR (Cardiopulmonary Resuscitation) began. No response. EMS (Emergency Medical Services) arrives. Time of death 414. (Physician S3) notified as well as administration."

Review of Patient #5's entire medical record revealed no documented evidence to indicate whether the patient had received 3 units or 16 units of regular insulin on 4/16/2010 at 8:00 p.m., no documented evidence of who pronounced the patient dead, no documented evidence to indicate if the coroner was notified of a death that occurred in the first 24 hours of admission, and no documented evidence to indicate if LOPA had been contacted. Further there was no documentation that the coroner approved release of the body to the funeral home. This findings was confirmed by the Director of Nursing S2 on 9/28/2010 at 1:40 p.m.

Review of Quality Assurance Performance Improvement Meeting Minutes revealed no documented evidence of an investigation of Patient #5's death that occurred within 24 hours of admission.

During a face to face interview on 9/30/2010 at 10:00 a.m., QAPI (Quality Assurance Performance Improvement) Director LPN (Licensed Practical Nurse) S16 indicated there had been no investigation into the death of Patient #5. S16 confirmed the hospital had not identified the conflicting information in Patient #5's medical record regarding the amount of insulin the patient had received on 4/16/2010 at 8:00 p.m. S16 confirmed there had been no identification of the hospital's failure to contact LOPA, and no identification of the hospital's failure to contact the Coroner to determine if the body could be released to the funeral home.


3)
Review of the following patient's records revealed the patients were diabetic and also on sliding scale insulin as per physician's orders #2, #3, #4, #5. Further review revealed no documented evidence that these patient's nursing care plans were updated to include sliding scale insulin administration with interventions for hypoglycemia or hyperglycemia.

During a face to face interview on 9/28/2010 at 2:30 p.m., Director of Nursing S2 confirmed the nursing care plans of Patients #2, #3, #4, and #5 did not include direction for care provided to the patients that addressed sliding scale insulin. S2 further indicated the nursing care plans of these patients should have included sliding scale insulin.

During a face to face interview on 9/30/2010 at 10:00 a.m., QAPI (Quality Assurance Performance Improvement) Director LPN (Licensed Practical Nurse) S16 indicated there had been no identification by the QAPI department that diabetic patients to include #2, #3, #4,and #5 did not have diabetes addressed on their care plans.

4)
Review of the hospital policy titled, "Capillary Blood Glucose Testing, N 2.020 (no documented date)" presented by the hospital as their current policy revealed in part, "Capillary blood glucose testing will be performed at intervals prescribed by the physician. Purpose: to provide all SRH (Specialty Rehabilitation Hospital) patients with quality nursing service in the treatment of diabetes." Review of the entire policy revealed no documented evidence of what discipline of staff were responsible for performing Capillary Blood Glucose testing.

Review of a letter dated 2/20/1995 from the Louisiana Board of Nursing revealed in part, "Your request for an opinion of the Board of Nursing regarding a registered nurse delegating to ancillary (unlicensed) personnel the performance of capillary blood glucose monitoring (Glucometer or Accucheck) was presented to the Board at it's February 15, 1995 meeting. The Nursing Practice Committee studied the issue, and at it's January 9,1995 meeting, the committee formulated a recommendation to the Board of Nursing. On February 15, 1995 the committee presented it's recommendation to the Board, and after due deliberation, the board adopted the following opinion. . . . Unlicensed personnel may not perform one-touch monitoring when insulin to scale is ordered."

During a face to face interview on 9/27/2010 at 10:40 a.m., Licensed Practical Nurse S5 indicated the hospital utilizes their Certified Nursing Assistants to perform Accucheck on all patients with orders for Accucheck and/or sliding scale insulin. This finding was confirmed by Director of Nursing (DON) S2 on 9/27/2010 at 11:00 a.m. who further indicated Registered Nurses (RN) and Licensed Practical Nurses (LPN) at the hospital have delegated Accucheck monitoring to non-licensed Certified Nursing Assistants. DON S2 further indicated she did not know that the Louisiana State Board of Nursing did not support delegation of Accucheck on patients with sliding scale insulin to non-licensed personal. DON S2 confirmed that Patients #2, #3, #4, and #5 were all patients on sliding scale insulins. DON S2 indicated Patients #2, #3, #4, and #5 would have had their Accucheck performed by Certified Nursing Assistants (CNA). S2 further indicated the CNA that performed the test would not have documented their name or initials in the medical records of the patients because the LPN or RN that transcribed the results would have placed their initials on the Diabetic Flow sheet rather than the CNA performing the test.

Review of the hospital policy titled, "Glucometer Quality Control Testing, N 2.060 (dated 7/10)" presented by the hospital as their current policy revealed in part, "Quality Control on the glucometer will be performed to ensure accurate and reliable testing using he high and low level control solutions. Quality Control testing will be performed nightly by the nursing staff. . . Registered Nurses and Licensed Practical Nurses are the staff members identified to perform quality control."

During a face to face interview on 9/30/2010 at 10:00 a.m., QAPI (Quality Assurance Performance Improvement) Director LPN (Licensed Practical Nurse) S16 and Director of Nursing S2 indicated they had not been aware that the Louisiana Board of Nursing required licensed professionals to perform Capillary Blood Glucose Testing on patients that would receive insulin as per sliding scale based on the results of the test. S16 indicated without that knowledge they would not have identified the hospital's practice of allowing non-licensed personal to perform Capillary Blood Glucose Testing as a problem.

5)
Review of the hospital's entire policy and procedure manual revealed no documented evidence of a policy directing the nursing care of patient's whose capillary blood glucose levels detected hyperglycemia. This finding was confirmed by QAPI (Quality Assurance Performance Improvement) Director LPN (Licensed Practical Nurse) S16 and Director of Nursing S2 on 9/30/2010 at 10:00 a.m.

6)
Patient #5: Review of Patient #5's medical record revealed the patient was admitted to the hospital on 4/16/2010 at 1440 (2:40 p.m.) with diagnoses that included Status Post Open Reduction Internal Fixation of left hip post fall, Metastatic Prostate Cancer, Dementia, Osteoporosis, and Renal Lesion. Review of Nurses Notes dated 4/17/2010 at 0350 (3:50 a.m.) revealed "went to pts (patients) room to, walked out, to add feeding to bag. Pt. found not breathing (and) non-responsive. Weak pulse found (at) carotid (and) then fades. RN (Registered Nurse) in (with) code cart. 911 called. CPR (Cardiopulmonary Resuscitation) began. No response. EMS (Emergency Medical Services) arrives. Time of death 414. (Physician S3) notified as well as administration." Review of the entire medical record revealed no documented evidence of a Registered Nurse evaluating Patient #5 for a change in condition on the 6 p.m. - 6 a.m. shift of 4/16/2010 through 4/17/2010 prior to the time the patient was found in cardiopulmonary arrest at 3:50 a.m.

During a telephone interview on 9/28/2010 at 1:40 p.m., Registered Nurse (RN) S10 indicated she was the Registered Nurse in charge of the hospital on 4/16/2010 from 6:00 p.m. until 4/17/2010 at 6:00 a.m. RN S10 further indicated that she was aware that LPN (Licensed Practical Nurse) S9 had been concerned about Patient #5 as evidenced by LPN S9 stating that she (S9) didn't like the way the patient looked. S10 further indicated that LPN S9 had been monitoring the patient (#5) closely all night. RN S10 further indicated that although she (S10) knew LPN S9 had been very concerned about Patient #5 that she (RN S10) had never gone to the patients room to perform a Registered Nurse assessment prior to 3:50 a.m. when she (RN S10) was called into the room because the patient (#5) had coded (experienced a cardio-pulmonary arrest).

Patient #2: Review of Patient #2's medical record revealed the patient was admitted to the hospital on 8/18/2010 with diagnoses that included Status post distal right tibia/fibula fracture with Open Reduction Internal Fixation, Poor Cognition, Hypertension, Diabetes with Neuropathy, Increased Lipids. Review of Patient #2's Discharge Summary revealed the diagnosis of "Uncontrolled diabetes with hypoglycemia and recent fever" was added. Further review revealed in part, " Discharge Disposition: To emergency room. . . Unfortunately she developed a hypoglycemic episode with a blood sugar of 27 at 5:00 a.m., She did receive one amp of Glucagon at 8:30 a.m. blood sugar was 97, however, patient was sent to emergency room for further evaluation. . ."

Review of Patient #2's medical record revealed the patient was ordered Sliding Scale Insulin Subcutaneously upon admission on 8/18/2010 at 5:20 p.m. as follows:
151 - 173 = 2 units, 174- 203 = 3 units, 204 - 233 = 4 units, 234 - 263 = 5 units, 264- 293 = 6 units, 294- 323 = 7 units, 324 - 353 = 8 units, 354 - 383 = 9 units, 384 - 413 = 10 units, 414 - 443 = 11 units, 444 - 450 = 12 units, and 450 and greater call MD (Medical Doctor). Initiate Hypoglycemic Protocol if BS (blood sugar) < 60 milligrams/ deciliter = retest and notify Medical Doctor. If symptomatic with decreased level of consciousness, give 1 amp (ampule) (1 milligram/milliliter) of Glucagon. Review of the entire medical record for Patient #2 revealed the patient's Sliding Scale Insulin order remained the same during the entire stay.

Review of the hospital policy titled, "Policy: Definitions of Critical Values (no documented date)" revealed in part, "For procedures performed for Specialty Hospital, the following values are considered critical values: Glucose: Low/ Less than 40 milligrams per deciliter, High/ greater than 400 milligrams per deciliter. . . These critical values may be laboratory, arterial blood gases values, or radiological results which are considered life threatening unless something is done promptly and/or for which some corrective action could be taken."

Review of Patient #2's medical record revealed the patient was documented as having Critical Capillary Blood Glucose (CBG) levels greater than 400 as follows:

-8/18/2010 at 1630 (4:30 p.m.): Patient #2's CBG was documented as 431 and #2 was treated with 11 units of Regular Insulin per sliding scale.
Review of Physician's orders for Patient #2 dated 8/18/2010 at 2110 (9:10 p.m.) revealed an order to give 12 units of Novolog Insulin Subcutaneously now and recheck Blood sugar at midnight. Cover Blood Sugar using Sliding Scale. Recheck again at 3:00 a.m.
Review of Patient #2's entire medical record revealed no documented evidence that Patient #2 had her CBG level repeated at midnight or at 3:00 a.m. as ordered by the patient's physician. This finding was confirmed by the Director of Nursing.
Review of Patient #2's entire medical record revealed the next assessment of CBG for Patient #2 did not occur until 8/19/2010 at 7:30 a.m. (10 hours and 20 minutes after the 9:10 p.m. Critical CBG).

-8/19/2010 at 1130 (11:30 p.m.): Patient #2's CBG was documented as 498 and #2 was treated with 12 units of Regular Insulin per sliding scale.
Review of Patient #2's entire medical record revealed no documented evidence of a follow up assessment of Patient #2's Critical Level CBG until the next scheduled accucheck on 8/19/2010 at 1650 (4:50 p.m./ 5 hours and 20 minutes later).

-8/19/2010 at 1650 (4:50 p.m.): Patient #2's CBG was documented as 504 and #2 was treated with 12 units of Regular Insulin per sliding scale.
Review of Patient #2's entire medical record revealed no documented evidence of a follow up assessment of Patient #2's Critical Level CBG until the next scheduled accucheck on 8/19/2010 at 2000 (8:00 p.m./3 hours and 10 minutes later.)

-8/24/2010 at 1630 (4:30 p.m.): CBG was documented as 469 and #2 was treated with 12 units of Regular Insulin.
Review of Physician's orders for Patient #2 dated 8/24/2010 at 5:00 p.m. revealed an order to repeat blood sugar in one hour.
Review of Patient #2's medical record revealed a follow up CBG was assessed on Patient #2 at 1810 (6:10 p.m.) as ordered by the physician. The results were 278.

-8/27/2010 at 2000 (8:00 p.m.): Patient #2's CBG was documented as 446 and #2 was treated with 12 units of Regular Insulin.
Review of Patient #2's medical record revealed a follow up CBG was documented on Patient #2 at 2200 (10:00 p.m.) which revealed a level of 292 (a drop of 154 in 2 hours). Review of the entire medical record revealed no further assessment of Patient #2's CBG until the patient was found to be unresponsive to tactile stimuli at 5:25 a.m. on 8/28/2010 (5 hours and 25 minutes after the last documented CBG).
Review of Patient #2's Nurses Notes/Narrative dated 8/28/2010 at 5:25 a.m. revealed in part, "upon entering room, calling pts (patient's) name, 0 (no) response (with) tactile stimuli (and) pts. skin feet, clammy . . . there was response (with) groaning to sternal rub but blinking eyes only, 0 (no) verbal response. . . 167/90 (blood pressure) - 80 (heart rate) - 16 (respirations) -96.0 (temperature) . 92% (oxygen saturation) RA (room air) sats (saturation); upon blood glucose check pts. (accucheck) (at) 27. 1 amp (ampule) glucagon given IM (Intramuscular) to L (left) UA (upper arm) (without) diff. (difficulty). MD (Doctor) notified (and) awaiting return call. will continue to closely monitor." 0526 (5:26 a.m.) physician returned call. 0535 (5:35 a.m.) ". . . blood sugar (increased) to 97. . continues to have involuntary twitching of BUE (bilateral upper extremities) and R (right) face area. . . instructed to call 911 for EMT (Emergency Medical Team). . ." 0612 (6:12 a.m.) "Blood sugar (at) 104 (patient transferred to Hospital B)."

During a face to face interview on 9/28/2010 at 11:15 a.m., Physician S3 (Medical Director) indicated Patient #2 had been running elevated CBG (Capillary Blood Glucose) levels for most of her stay. S3 further indicated the patient (#2) appeared to have a Urinary Tract Infection which would possibly have increased her glucose levels. S3 indicated he had started #2 on Cipro 500 milligrams by mouth twice a day on 8/09/2010 (confirmed with record review). S3 further indicated he (S3) had steadily increased Patient #2's Lantus during her (#2) hospital stay due to a pattern of elevated CBG levels. S3 indicated that he would typically order nursing staff to repeat a blood glucose level in 2 hours after treating a critical CBG level and then order another repeat two hours after that. S3 further indicated he did not always verbalize that expectation. Physician S3 indicated it would be difficult to tell why Patient #2's CBG dropped to 27 on the morning of 8/27/2010 at 5:25 a.m. Physician S3 indicated the patient may have eaten or drank a sugar substance around the time of her 8:00 p.m. accucheck which would have given her a rapid increase in blood sugar followed by a rapid decrease in blood sugar. Physician S3 further indicated that in hindsight it may have been helpful if he (S3) had adjusted her (#2's) sliding scale insulin as he (S3) went up on her Lantus Insulin; however, at the time there had been no indication of a need to change the Sliding Scale.

During a face to face interview on 9/28/2010 at 10:00 a.m., Registered Nurse (RN) S11 indicated she had been the nurse caring for Patient #2 on the night shift of 8/27/2010 through the morning of 8/28/2010. RN S11 further indicated that although she typically would not have repeated a CBG level after treating a patient with insulin for sliding scale when she worked day shift, that she did repeat the CBG on Patient #2 at 10:00 p.m. after treating a 446 CBG with 12 units of insulin at 8:00 p.m. RN S11 indicated her rationale was that patients would be very active during the day and she would have been able to visualize symptoms of hypoglycemia during the day hours; however at night the patient would be sleeping and she would not be able to notice changes indicating hypoglycemia in the patient. S11 indicated Patient #2 had received a good bit of insulin (12 units) at 8:00 p.m. and she (S11) felt it necessary to recheck the CBG at 10:00 p.m. S11 indicated she (S11) had not felt it necessary to repeat it again after seeing the level was 292 at 10:00 p.m. The Director of Nursing was present during this interview and confirmed the hospital had no policy for treating hyperglycemia per sliding scale to include follow up assessments post insulin administration for critical value blood glucose levels.

During a face to face interview on 9/30/2010 at 10:00 a.m., QAPI (Quality Assurance Performance Improvement) Director LPN (Licensed Practical Nurse) S16 confirmed the hospital had never identified failure to followup on critical value Capillary Blood Glucose levels as a problem prone area in need of corrective action.

Based on record review and interview the hospital failed to ensure conflicting medication orders were clarified prior to the administration of insulin for 1 of 5 sampled patients (#4) resulting in a total of 14 administrations of sliding scale insulin without a clear order for administration over a 5 day period (9/04/2010 through 9/09/2010). Findings:

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 9/03/2010 with diagnoses that included Respiratory Failure, Pneumonia, Sepsis, Chronic Obstructive Pulmonary Disease, and Diabetes with Neuropathy. Further review revealed the patient was ordered sliding scale insulin 9/03/2010 at 4:00 p.m. as follows:
Sliding Scale Regular Insulin Subcutaneous:
150 - 200 (Administer) 3u (units)
201 - 250 (Administer) 5u (units)
251 - 300 (Administer) 10 (units)
301 - 350 (Administer) 15 (units)
351 - 449 (Administer) 20 (units)
<60- Stat FBS (fasting blood sugar) and 1 amp (ampule) of D50W, call MD (medical doctor)
If BG (blood glucose) >450 - 25 units.
If BG > 401 call MD.
Further review revealed physician's orders dated 9/03/2010 at 4:00 p.m. (same date and time as above order) indicating "follow routine sliding scale coverage"
Routine Sliding Scale Coverage:
151 - 173 = 2 units
171-203 = 3 units
204 - 233 = 4 units
234 - 263 = 5 units
264 - 293 = 6 units
294 - 323 = 7 units
324 - 254 = 9 units
384 - 413 = 11 units
414 - 443 = 11 units
444 - 450 = 12 units
450 and greater - call MD
Review of the entire medical record revealed no documented evidence of clarification of the conflicting orders for insulin signed by Physician S3 at the same date and time (9/03/2010 at 4:00 p.m.).

Review of Patient #4's Diabetic Flowsheet revealed the following:
9/04/2010 at 1130 (11:30 a.m.) Results (Accucheck) 172, Coverage Amount 2 units (Physician's orders indicated the patient should have received 3 units for a blood glucose from 150 - 200 on one physician ordered sliding scale and 2 units on another physician ordered sliding scale for 151 - 173. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/04/2010 at 1630 (4:30 p.m.) Results 207, Coverage Amount 4 units
(Physician's orders indicated the patient should have received 5 units for a blood glucose from 201 - 250 on one physician ordered sliding scale and 4 units on another physician ordered sliding scale for 204 - 233. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/04/2010 at 2000 (8:00 p.m.) Results 320, Coverage Amount 7 units
(Physician's orders indicated the patient should have received 15 units for a blood glucose from 301 - 350 on one physician ordered sliding scale and 7 units on another physician ordered sliding scale for 294 -323. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/05/2010 at 0730 (7:30 a.m.) Results 170, Coverage Amount 2 units
(Physician's orders indicated the patient should have received 3 units for a blood glucose from 150 - 200 on one physician ordered sliding scale and 2 units on another physician ordered sliding scale for 151 - 173. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/05/2010 at 1130 (11:30 a.m.) Results 170, Coverage Amount 2 units
(Physician's orders indicated the patient should have received 3 units for a blood glucose from 150 - 200 on one physician ordered sliding scale and 2 units on another physician ordered sliding scale for 151 - 173. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/05/2010 at 1630 (4:30 p.m.) Results 375, Coverage Amount 9 units
(Physician's orders indicated the patient should have received 20 units for a blood glucose from 351 - 449 on one physician ordered sliding scale and 9 units on another physician ordered sliding scale for 354 - 383. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/05/2010 at 2000 (8:00 p.m.) Results 377, Coverage Amount 9 units
(Physician's orders indicated the patient should have received 20 units for a blood glucose from 351 - 44 9 on one physician ordered sliding scale and 9 units on another physician ordered sliding scale for 354 - 383. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/06/2010 at 1630 (4:30 p.m.) Results 362, Coverage Amount 9 units
(Physician's orders indicated the patient should have received 20 units for a blood glucose from 351 - 449 on one physician ordered sliding scale and 9 units on another physician ordered sliding scale for 354 - 383. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/06/2010 at 2000 (8:00 p.m.) Results 305, Coverage Amount 7 units
(Physician's orders indicated the patient should have received 15 units for a blood glucose from 301 - 350 on one physician ordered sliding scale and 7 units on another physician ordered sliding scale for 294 - 323. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/07/2010 at 1130 (11:30 a.m.) Results 160, Coverage Amount 2 units
(Physician's orders indicated the patient should have received 3 units for a blood glucose from 150 - 200 on one physician ordered sliding scale and 2 units on another physician ordered sliding scale for 151 - 173. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/07/2010 at 1630 (4:30 p.m.) Results 316, Coverage Amount 7 units
(Physician's orders indicated the patient should have received 15 units for a blood glucose from 301 - 350 on one physician ordered sliding scale and 7 units on another physician ordered sliding scale for 294 - 323. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/08/2010 at 1130 (11:30 a.m.) Results 169, Coverage Amount 2 units
(Physician's orders indicated the patient should have received 3 units for a blood glucose from 150 - 200 on one physician ordered sliding scale and 2 units on another physician ordered sliding scale for 151 - 173. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/08/2010 at 1630 (4:30 p.m.) Results 329, Coverage Amount 8 units
(Physician's orders indicated the patient should have received 15 units for a blood glucose from 301 - 350 on one physician ordered sliding scale and 8 units on another physician ordered sliding scale for 384 - 413. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
9/09/2010 at 1630 (4:30 p.m.) Results 275, Coverage Amount 6 units
(Physician's orders indicated the patient should have received 10 units for a blood glucose from 251 - 300 on one physician ordered sliding scale and 6 units on another physician ordered sliding scale for 264 - 293. Both sliding scales ordered same date and time- 9/03/2010 at 4:00 p.m..)
These findings were confirmed by Director of Nursing S2 on 9/30/2010 at 3:00 p.m.

During a face to face interview on 9/28/2010 at 9:40 a.m., Registered Nurse S11 confirmed the above findings. S11 further indicated the hospital had a system in place for chart checks to ensure orders were properly transcribed and someone should have caught the error and clarified the orders.

Review of the hospital policy titled, "24 Hour Chart Check, N.2.004 (no documented date)" presented by the hospital as their current policy revealed in part, "It is the policy of Specialty Rehabilitation Hospital to complete a 24 hours chart check on each patient every day. Purpose: to provide a double check system to ensure completeness of each patient chart. Procedure: A. All physician orders have been completed, dated, time the order was given, signed and transcribed correctly. . . ."