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Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 104 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-08-23 | 760 | D | 0 | 1 | TKSO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interviews, the facility failed to prevent a significant medication error from occurring for one of 12 sampled residents (Resident #120) who was reviewed for medication administration. Resident #120 was administered long acting insulin that was prescribed for another resident. Resident identifier: #120. Facility census: 176. Findings included: a) Resident #120 An interview was conducted with Resident #120 on 08/20/18 at 11:05 AM. Resident #120 stated that a male nurse (Nurse #4), who she referred to as the medicine man had administered insulin to her in her belly (abdomen) although she is not diabetic. She repeated this again stating that, He gave me an insulin needle in my belly. She also stated that Nurse #4 had administered the insulin injection on the day prior to this interview which was Sunday, 08/19/18. Resident #120 went on to say that she had specifically asked Nurse #4 why was she receiving the insulin injection as she was not diabetic. Resident #120 reported that Nurse #4 gave her the insulin injection anyway and stated, Well, you're supposed to get it. Resident #120 also stated that Nurse #4 checked her blood sugar level after he had administered the insulin injection. She said he told her that the blood sugar reading was 108 and showed it to her on the blood sugar monitor. Resident #120 said that Nurse #4 told her it was fine. Resident #120 stated that Nurse #4 did not check her blood sugar level before administering the insulin injection. Additionally, Resident #120 voiced that she did not report the insulin administration incident to any other facility staff but said she did call her family member and informed him of the incident on the same day that the incident occurred, Sunday, 08/19/18. A review of the clinical record was conducted for Resident #120 on 08/20/18 at approximately 12:05 PM. The admission record, which listed the resident's diagnoses, indicated that Resident #120 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Neither the admission record nor any other part of the clinical record indicated that Resident #120 had a [DIAGNOSES REDACTED].#120 and failed to indicate that Resident #120 had a physician's orders [REDACTED]. A review of the admission MDS (Minimum Data Set) assessment was conducted on 08/20/18 at approximately 12:35 AM. The MDS, dated [DATE], had the resident coded as having a BIMS (Brief Interview for Mental Status) summary score of 15 indicating the resident's cognition was intact. Resident #120 was also coded as being oriented to year, month and date as well. Resident #120 was not coded as having a [DIAGNOSES REDACTED]. An interview was conducted with the Unit Manager, Nurse (#34) on 08/20/18 at approximately 12:50 PM. Nurse #34 stated that she was aware of the allegation involving the insulin error as Resident #120's family member came in earlier that morning before lunch and brought it to her attention. Nurse #34 confirmed that Resident #120 did not have a physician's orders [REDACTED]. Nurse #34 also reviewed the daily staffing report with this writer and confirmed that Nurse #4 was on duty the previous day when Resident #120 alleged having received an insulin injection. Nurse #34 also conveyed that Nurse #4 is a PRN (works as necessary) nurse and worked from 7AM -7PM on 08/19/18. Nurse #34 stated that another nurse, Nurse #113 was the unit manager that was on duty at the time of the insulin administration error and that Nurse #113 typically worked a double shift on the weekends from 7AM-11:30 PM. Initial attempts to call Nurse #4 and Nurse #113 were unsuccessful. Voicemail messages were left for each of these nurses. An interview was later conducted with Nurse #4 on 08/20/18 at 3:21 PM. Nurse #4 stated that he came back to the facility at the request of the Director of Nursing (DON). Nurse #4 stated, If you're asking about the insulin, yes, I made a mistake. I'll own up to it. I was supposed to give it to a resident across the hall. This is only the second time that I worked down there (referring to the hallway where Resident #120 resides.) I only have the computer to go by. I don't really know the people. I just made a mistake. Nurse #4 stated, As soon as I gave it to her (Resident#120) she said, But I'm not a diabetic. Why am I getting insulin? Nurse #4 stated that he had administered 30 units of [MEDICATION NAME]to Resident #120. Nurse #4 stated, I went by the name and the picture on the MAR (Medication Administration Record) when asked which identifiers were used to correctly identify Resident #120 as the correct resident to receive the 30 units of [MEDICATION NAME] insulin. Nurse #4 also stated, They are very similar referring to the appearance of Resident #120 and the other resident across the hall who he said was supposed to receive the insulin. Nurse #4 stated, I'm sick to death over it. I've never done anything like this before. During the same interview with Nurse #4 he stated that he knew right away that he had made a mistake and immediately reported the incident to his unit manager (Nurse #113). Nurse #4 shared that he did not call the physician after the incident, but that his unit manager, Nurse #113, had done so. He also stated that Nurse #113 gave him instructions to check Resident #120's blood sugar level three more times as ordered by the physician. Nurse #4 stated that he checked Resident #120's blood sugar levels at least three more times after administering the insulin. Nurse #4 recalled checking Resident #120's blood sugar immediately after administering the insulin and received 108. He acknowledged showing the blood sugar monitor result to Resident #120. He also reported checking the resident's blood sugar level again after lunch which was 103, before dinner, which was 93 and again after dinner around 5:30 PM. At 5:30 PM he stated that the resident's blood sugar level was 91. Nurse #4 voiced that he had written an incident report and pinned it up on the incident board before leaving work. He also recalled reporting the incident to the oncoming nurse that worked the 7PM-7AM shift. An interview was conducted with Nurse #113 on 08/20/18 at approximately 3:38 PM who confirmed that she was on duty at the time of the alleged insulin incident. She stated she worked from 7 AM - 2 AM on Sunday, 08/19/18. Nurse #113 recalled that Nurse #4 came to the desk and informed her that he had administered 30 units of [MEDICATION NAME]to the wrong resident. Nurse #113 also recalled Nurse #4 having notified Resident #120 that he had mistakenly given her insulin that was meant for another resident. Nurse #113 confirmed that she called the physician and notified the physician of the medication error that had occurred with Resident #120. She said she informed the physician that Resident #120 received 30 units of [MEDICATION NAME]and that Resident #120 was not diabetic. Nurse #113 also stated that the physician gave her an order to monitor Resident #120's blood sugar level three more times. Nurse #113 shared with this writer that the peak time for [MEDICATION NAME]was eight hours and Resident #120's blood sugar level never dropped below 91. Nurse #113 also stated that she went down to the room of Resident #120 after the incident had occurred and that Resident #120 reiterated the same story to her that Nurse #4 had previously communicated to her about the insulin error. Nurse #113 also stated that Nurse #4 had apologized to Resident #120. Nurse #113 stated that both she and Nurse #4 were very open with Resident #120 about the incident and that Resident #120 was aware of the incident and what had occurred. Nurse #113 also stated that Resident #120 had eaten all her meals that day and that she was fine (without symptoms of a low blood sugar reaction). Nurse #113 conveyed that nurses are supposed identify residents by checking the name on door check their arm bands and using the pictures on the MAR. Nurse #113 stated, Had Nurse #4 done that, yes, he should have known that it wasn't the right resident. Resident #120 was re-interviewed on 08/20/18 at approximately 4:22 PM to clarify if Nurse # 4 had checked her blood sugar before he administered the insulin. Resident #120 was quite certain that Nurse #4 did not check her blood sugar before giving her the insulin injection. The incident/accident report was reviewed on 08/22/18 at approximately 4:45 PM. The report conveyed that [MEDICATION NAME] 30 units was given in error on 08/19/18. The report also indicated that the physician was notified. Under the section entitled action the report indicated that the blood sugar level was checked immediately, and that snacks were also offered. The incident report also listed blood sugar checks that were conducted at the following times on 08/19/18: 10:00 AM-BS=108 11:00 AM -BS =103 1:30 PM -BS =93 5:00 PM- BS =91 The incident report was signed by Nurse#4 as having prepared the report and was also signed by the DON. The incident report indicated that the physician, unit manager (Nurse #113) and Resident #120 were each notified that [MEDICATION NAME] 30 units was given in error. The medication variance report was also reviewed on 08/22/18 at approximately 4:58 PM. The variance report indicated that [MEDICATION NAME] 30 units SQ (subcutaneous) was given in error and the error type was listed as wrong resident. An interview was conducted with the DON on 08/20/18 at approximately 4:30 PM. The DON stated that she was aware of the medication error involving both Resident #120 and Nurse #4. The DON shared that the incident report was completed before she arrived to work on the morning of 08/20/18. She conveyed that someone slid the incident report and the medication variance report under the door to her office over the weekend. The DON also stated that it was her expectation that the nursing staff use two resident identifiers to correctly identify their residents during medication pass. A review of the facility's policy regarding safe medication practices was reviewed and was dated (MONTH) 17, (YEAR). The policy indicated the following: To promote a culture of safety and prevent medication errors, nurses must adhere to the rights of medication administration: --Identify the right resident by using at least two resident identifiers. --Select the right medication --Give the right dose --Give the right medication at the right time --Give the medication by the right route --Provide the right documentation Under the section entitled Implementation the policy also indicated in part, confirm the resident's identity using as least two resident identifiers. | 2020-09-01 |