HospitalInspections.org

Based on document review and staff interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to completing Accuchecks and administration of insulin per physician orders for 1 of 5 (#1) closed patient medical records reviewed.

Findings:

1. Policy TJC: LD 04.03.07, NR 01.01.01, Guidelines for Nursing Care, revised/reapproved 3/24/2014, indicated on pg. 1, under Medical Record section, and on pg. 3, under Medication Administration Record (MAR) section, "Physician orders and documentation checked and chart signed off by nurse, every 12 hours...Med reconciliation completed, every night."

2. Review of Incident Reports (IRs) and Patient/Family Complaints indicated:
A. on 12/27/15 at 2100 hours, an IR related to poor control of blood sugars was filed. Allegation was that Accuchecks were not being done as ordered and elevated blood sugars were not being appropriately controlled. Follow-up included physician writing new orders for insulin types and dosages with sliding scale coverage and education was provided to nursing staff and the patient.
B. on 12/31/15 at 2100 hours, an IR related to insulin sliding scale not being followed for an elevated blood sugar. Follow-up included nursing staff being informed to follow insulin orders and orders were reviewed with physician.

3. Review of patient #1's medical record confirmed:
A. history and physical dated 12/21/15 stated patient had insulin dependent diabetes mellitus type 2. Physician order dated 12/27/15 was for Accuchecks before meals and at bedtime. Accuchecks were not done as ordered on 12/30/15, 12/31/15, 1/2/16 and 1/3/16, having been done only 3 times and not 4.
B. physician order dated 12/21/15 was for moderate sliding scale for insulin coverage. The parameters for the moderate sliding scale were for blood sugar of:
60-150 0 units of Regular Insulin
151-200 2 units of Regular Insulin
201-250 4 units of Regular Insulin
251-300 6 units of Regular Insulin
301-350 8 units of Regular Insulin
351-400 10 units of Regular Insulin
>400 12 units of Regular Insulin and call physician.
C. lacked insulin coverage as ordered for elevated blood sugars of 216 and 285 on 12/23/15; 286 and 389 on 12/24/15; 206, 268 and 195 on 12/25/15; 154 and 336 on 12/26/15; 322, 318, 178 and 360 on 12/27/15; 276 and 162 on 12/28/15; 174, 191 and 184 on 12/29/15; 153, 196, 270, 224 and 208 on 12/30/15; 229 and 307 on 12/31/15; 241, 243, 182 and 227 on 1/1/16; 203, 232, 157 and 232 on 1/2/16; 167, 227 and 152 on 1/3/16; 169 on 1/4/16; 286, 213 and 196 on 1/5/16; 158 and 234 on 1/6/16; 242 and 248 on 1/7/16; 193, 207 and 196 on 1/8/16.

4. Staff 5 (Director of Pharmacy) was interviewed on 1/26/16 at approximately 1525 hours, and confirmed patient #1 lacked blood sugar checks (Accuchecks) as ordered on several days and physician order dated 12/21/15 was for moderate sliding scale for insulin coverage. Blood sugars were repeatedly 151 or above that were not covered per the moderate sliding insulin coverage scale and physician orders were not followed as required per facility policy and procedure.