| 90 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2017-07-19 |
333 |
G |
1 |
1 |
ZBS111 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record reviews, interviews and review of other facility documents it was determined that the facility failed to ensure that 6 (R40, R71, R91, R117, R181, and R196) out of 55 Stage 2 sampled residents were free of significant medication errors. Thirteen (13) Units of Humalog insulin was administered to R196 when the blood sugar value was 88 causing R196's blood sugar level to drop to 21 resulting in the resident becoming unresponsive and requiring emergency interventions. Additionally, there was no documented evidence that R196 was receiving and/or consuming bedtime snacks. The facility failed to ensure for R71 and R181 that Humalog insulin was administered according to manufacturers specifications, specifically within 15 minutes before a meal or immediately after a meal. For R40, R91, and R117, the facility failed to ensure that [MEDICATION NAME]was administered according to manufacturers specifications, specifically within 5-10 minutes before a meal. Findings include: The manufacturer's package insert (http://uspl.lilly.com/humalog/humalog.html) for Humalog insulin stated, .INDICATIONS AND USAGE: HUMALOG is a rapid acting human insulin .DOSAGE AND ADMINISTRATION: .Administer HUMALOG .within 15 minutes before a meal or immediately after a meal . The manufacturer's package insert (http://www.novo-pi.com/[MEDICATION NAME].pdf) for [MEDICATION NAME]stated, .INDICATIONS AND USAGE: [MEDICATION NAME] is rapid acting human insulin .DOSAGE AND ADMINISTRATION: .Inject .within 5-10 minutes before a meal . 1[NAME] Review of R196's clinical record revealed the following: 4/14/17 - R196 was admitted to the facility with [DIAGNOSES REDACTED]. 4/14/17 - A physician's orders [REDACTED]. The order stated that when R196's Accu-Chek result was 0 to 199, no SSI coverage was to be given. 4/19/17 - R196's progress notes stated: 7:00 AM - Orders-Administration Note: (MONTH) initiate I.V. access in potentially critical situations as needed. Then notify physician for further orders. 7:30 AM - .I was called to pt's bedside due to AMS and low BG of 21 at approximately 0730. Nurse in charge of pt at that time stated to me that she gave pt 13 units of insulin when her BG was 88. This progress note was completed by the P[NAME] 7:55 AM - This nurse went in to resident room to do rounds and saw resident unresponsive. Upon assessment, resident BS is 21, [MEDICATION NAME] 1 amp IM was administered and after 30 mins BS was 23, (name of PA) was in the building gave a verbal order for another [MEDICATION NAME] 1 amp IM to be administered 911 was called. At 0801 resident became responsive with BS at 224. Resident decline (sic) to go to the hospital and is eating her breakfast in her room at this time. 4/19/17 10:02 AM - A physician's medical visit note stated, .BS this am 88 but apparently given extra dose 13 units and BS dropped to 21 [MEDICATION NAME] administered; BS 200s pt denies any complaints now. Review of the facility's incident investigation revealed the following statements: 4/19/17 (Completed by E12 (Agency LPN)) - Blood sugar was checked by this nurse at about 0630 a.m. Resident is on a sliding scale of insulin, blood sugar protocol was followed as order (sic). At about 0708 Unit Manager was doing her rounds and discovered pt being hypoglacemic (sic). Followed the order/care as 13 unit (sic) of insulin was administered. While the Agency LPN wrote in her statement that blood sugar protocol was followed this was not correct since insulin was administered for a blood sugar of 88. 4/19/17 (Completed by E13 (Greenbank UM)) - I responded to a page overhead. Resident observed unresponsive. BS was in the 20's. I started an IV in the right arm. EMS arrived as soon as I finished and they took over. 4/19/17 (Completed by E3 (Staff Education RN)) - This nurse was overhead paged .Upon arriving in room noted resident in bed not responding to nurse manager. Resident had a BS of 21 .I contacted PA who was in facility who gave me order to call 911. Myself & PA (name) asked nurse how much [MEDICATION NAME] they administered and nurse went to check & returned and stated 13 units. This nurse asked nurse again did you administer 13 units of [MEDICATION NAME] to a resident who had a BS of 88 and nurse stated 'Yes she did.' I asked the nurse again if she was sure & she stated 'Yes.' 4/19/17 12:45 PM - The facility's Incident Report submitted to the State Agency stated, Agency Nurse administered 13 units of insulin for .88. Resident found unresponsive. According to agency nurse insulin was administered at 0630 and resident was found .at approximately 0700. IV access initiated and PA in building and made aware. Paramedics arrived and administered D50. Resident became AAO3 and refused hospitalization .resident currently in no acute distress. Agency nurse banned from building. Agency and MD aware. The facility failed to ensure that R196 was free of a significant medication error. R196 was given Humalog insulin 13 units when no insulin coverage was required. R196 became unresponsive with a severely low BS requiring the administration of 2 amps of [MEDICATION NAME], insertion of an IV and administration of D50. This deficient practice resulted in harm to R196. On 7/18/17 at approximately 4:15 PM, findings were reviewed with E1 (NHA) and E2 (DON). E1 and E2 acknowledged the findings and stated that E12 has been banned from working in the facility. 1B. R196 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to the B wing (where R196 resided) at 8:10 AM. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Although the Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 40 minutes before breakfast was served. R196 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. Review of the MAR from 4/14/17 through 5/18/17 revealed that R196 received SSI coverage, signed off at 6:30 AM, on the following dates: 4/17/17, 4/18/17, 4/19/17, 4/20/17, 4/26/17, 4/30/17, 5/1/17, 5/9/17, 5/10/17, 5/14/17 and 5/16/17. R196 had a physician's orders [REDACTED]. On 5/20/17, a physician's orders [REDACTED]. This order was in addition to the Humalog SSI coverage before meals which was also written on 5/20/17 and stated to HOLD if not eating. Review of the MAR indicated [REDACTED]. Additionally, the MAR indicated [REDACTED]. The facility failed to ensure that R196 was eating breakfast before administering the Humalog insulin as it was being administered by the night shift, who were off duty at 7:30 AM, and breakfast was not delivered until 8:10 AM, a potential one and three quarter hour delay. On 6/13/17, R196 had in total, the following insulin orders before breakfast: - Basaglar KwikPen insulin 6 units daily; - Humalog insulin 3 units daily, to be held if not eating; - Humalog SSI coverage, amount dependent on Accu-Chek result and to be held if not eating. Review of the 6/13/17 MAR indicated [REDACTED] - Basaglar KwikPen 6 units, signed off given by the day shift (7 AM - 3:30 PM) nurse; - Humalog 3 units, signed off by the night shift nurse at 6:30 AM. Despite the fact that it was to be held if not eating. Breakfast trays are scheduled to be delivered to the wing at 8:10 AM, potentially one and three quarter hours after administration of the fast acting Humalog insulin. Humalog SSI coverage was not given, as R196's 6:30 AM Accu-Chek was 82 and no coverage was ordered. Review of the meal intake record for 6/13/17 revealed R196 consumed only 25% of breakfast. A progress note, dated 6/13/17 and timed 11:54 AM, stated, This nurse was called to the resident room .BS 54. [MEDICATION NAME] was given x 2. Resident was rechecked and BS was 175. Resident was seen by NP (name) and advised to be sent to ER for further evaluation. The facility failed to ensure that R196's insulin orders were followed when on multiple occasions insulin was administered when nursing staff was unaware if the resident was eating and they failed to administer fast acting insulin (Humalog) according to manufacturer's specifications. R196 was admitted to the hospital from 6/13/17 through 6/29/17. A hospital progress note, dated 6/28/17, stated, .difficult to control .diabetes .dose has been altered multiple times .usually indicative of an acquired disorder, rather than having any connection with food intake or activity. It is very difficult to control . R196 returned to the facility on [DATE]. Readmission physician orders, dated 6/29/17, included: - Humalog SSI coverage before meals, dependent on Accu-Chek results and hold if not eating; - Humalog 3 units before breakfast, hold if not eating; - Nepro 8 ounces three times a day, timed on the MAR for 6:30 AM, 11:30 AM and 9:00 PM. The MAR indicated [REDACTED]. Both of these insulin orders stated to hold if not eating, however both were signed off at 6:30 AM and breakfast was not delivered to the unit until 8:10 AM. Observation on 7/12/17 at 8:00 AM revealed R196 asleep in bed with an unopened can of Nepro on the over bed tray table next to her. On 7/18/17 at approximately 4:15 PM, findings were confirmed by E1 and E2. During an interview on 7/19/17 at approximately 4:00 PM, E3 (RN, Staff Educator) stated that Nepro was timed to be given at 6:30 AM in an attempt to decrease R196's episodes of low blood sugars. When E3 was told of the observation on 7/12/17 at 8:00 AM of an unopened can of Nepro, she stated that the nurse needs to ensure the resident drinks it. 1C. Review of the facility's B Wing Nourishment List revealed that R196 was listed as receiving an assorted 8:00 PM snack. Review of the clinical record lacked documented evidence that R196 was receiving and/or consuming the bedtime snacks. During an interview on 7/19/17 at approximately 11:15 AM, E16 (RD) stated that bedtime snacks are not documented in the clinical record, however if a resident refuses or does not consume, it should say so in a nurse's progress note. 2. Review of R71's clinical record revealed the following: R71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R71 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R71 resided) at 8:10 AM. Review of the April, May, (MONTH) and (MONTH) 1-19, (YEAR) MARs revealed that Accu-Cheks were completed by the night shift (11 PM- 7:30 AM) and signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 40 minutes before breakfast was served. R71 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. Review of the (MONTH) 1- (MONTH) 19, (YEAR) MARs revealed that R71 received SSI coverage, signed off at 6:30 AM on the following dates (except 5/20- 5/24/17 when in hospital) : 4/29, 4/30, 5/1-5/3, 5/5-5/19, 5/25-5/31, 6/1-6/30, 7/1-7/19/17. 3. Review of R40's clinical record revealed the following: R40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R40 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to C wing (where R40 resided) at 7:50 AM. Review of the May, June, and July1-19, (YEAR) MARs revealed that R40 received SSI coverage, signed off at 6:30 AM on the following dates (except 5/2- 5/15/17 when in hospital): 7/3 and 7/17/17. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 20 minutes before breakfast was served. R71 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes of a meal. 4. Review of R181's clinical record revealed the following: R181 had a physician's orders [REDACTED]. R181 also had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to C wing (where R181 resided) at 7:50 AM. Review of the April, May, June, and (MONTH) (YEAR) MARs revealed that Accu-cheks were completed by the night shift (11:00 PM- 7:30 AM) and the Humalog SSI if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of 20 minutes before breakfast was served. R181's standing order of 8 units of Humalog insulin if received was signed off at 7:30 AM. R181 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. 5. Review of R117's clinical record revealed the following: R117 had a physician's orders [REDACTED]. R117 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R117 resided) at 8:10 AM. Review of the April, May, June, and (MONTH) (YEAR) MARs revealed that Accu-cheks were completed by the night shift (11:00 PM- 7:30 AM) and the [MEDICATION NAME] insulin, if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and [MEDICATION NAME]given at that time, there was still a delay of 40 minutes before breakfast was served. R117 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes before a meal (although ordered to be given 10-15 minutes before meal). 6. Review of R91's clinical record revealed the following: R91 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R91 resided) at 8:10 AM. Review of the April, May, June, and (MONTH) (YEAR) MARs revealed that Accu-Cheks were completed by the night shift (11:00 PM- 7:30 AM) and the [MEDICATION NAME]sliding scale, if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and [MEDICATION NAME]given at that time, there was still a delay of 40 minutes before breakfast was served. R91 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes before a meal. All findings for this citation were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 7/19/17 at approximately 6:45 PM. |
2020-09-01 |