cms_TN: 14001
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 14001 | TENNESSEE STATE VETERANS HOME | 445366 | 2865 MAIN STREET | HUMBOLDT | TN | 38343 | 2009-08-12 | 333 | K | 1 | 0 | R86C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy reviews, review of inservice records, review of meal times, review of the "MED-PASS" provided by the American Society of Consultant Pharmacists, medical record review, observations and interviews, it was determined the facility failed to ensure that residents were free of significant medication errors. The nursing staff failed to obtain blood sugars (BS) as ordered, failed to administer correct dosages of sliding scale insulin (SSI) as ordered, failed to administer insulin within 30 minutes of meals and/or failed to obtain signed orders for insulin administration for 20 of 30 (Residents #4, 10, 11, 17, 18, 19, 20, 24, 26, 29, 32, 34, 35, 36, 37, 38, 40, 42, 43 and 46) sampled diabetic residents. The failure to administer insulin as ordered, obtain BS as ordered and/or notify the physician of BS below 60 and/or above 401, placed all residents receiving insulin in immediate jeopardy. The immediate jeopardy began 7/29/09. The facility remained out of compliance at a scope and severity level "E" (a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the policies and procedures and training implemented by the facility could be reviewed by the Quality Assurance (QA) Committee. The findings included: 1. Review of the facility's "Medication Administration General Guidelines" policy documented "...b. Medications to be given with meals are to be scheduled for administration at the resident's meal times..." Review of the facility's "Blood Sugar/Sliding Scale Monitoring" policy provided by the facility to be used as the standing order for sliding scale insulins documented, "...1.) A written physician order for [REDACTED]. (greater than) 401 call MD... 2.) Physician orders for custom sliding scale intervention may be written specifically for individual residents by the Physician and will supercede the facility approved sliding scale... 3.) Signs and symptoms of [DIAGNOSES REDACTED]: a.) Early symptoms: Sweating...Tremor...Pallor... [MEDICAL CONDITION] 4.) Treat [DIAGNOSES REDACTED] promptly with: a.) 4 oz. (ounces) juice, b.) 1 cup skim milk, c.) 4 packets sugar, or d.) [MEDICATION NAME] 1 mg (milligram) (subcutaneously (SQ) or I.M. (intramuscular)) is given if the resident cannot ingest a sugar treatment..." During an interview in the conference room on 8/5/09 at 2:30 PM, the Director of Nurses and the Regional Compliance Nurse was asked what the staff is supposed to use for sliding scale insulin. The Compliance Nurse stated, "...They (nurses) should go with what the order says, unless there's a clarification order to convert to the protocol, they should use the doctor's order... should have a standing order signed by (named medical director)... should be signed by all the doctors..." During an interview in the conference room on 8/5/09 at 4:00 PM, the Compliance Nurse was asked how the staff knows which regular insulin to use. The Compliance Nurse stated, "...I see what you mean...I'll rewrite the policy...I'll call (named medical director) and ask her..." 2. During an interview in the conference room on 8/11/09 at 9:45 AM, the Regional Compliance Nurse stated that the Quality Assessment (QA) process started in March 2009 concerning problems with compliance with diabetic residents. The Regional Compliance Nurse stated, "...That's when they (facility) started terminating people (failing to perform accuchecks as prescribed, notifying physician of low and high blood sugars and administering insulin as ordered) ...did group education...maybe we should do one-on-one..." As a result of the QA findings in March 2009 the facility did a nursing inservice on 3/29/09 as follows: "...Topics ...4. Accucheck & (and) Insulin Policy and Procedure...6. Physician and Family Notification... Accucheck and Insulin Policy and Procedure... 1. Accuchecks are to be performed as prescribed. The Accucheck will be documented on the Accucheck and Insulin flow sheet... If the Accucheck is below 60 or above 401 or as stated by the Physician, YOU MUST NOTIFY THE ATTENDING PHYSICIAN AND DOCUMENT. Document that the MD was notified and what the results of the notification are. FAILURE TO DO THIS WILL RESULT IN DISCIPLINARY ACTION LEADING VERY QUICKLY TO TERMINATION... 2. Scheduled Insulin will be given as directed. If there is a reason to hold the insulin, YOU WILL NOTIFY THE ATTENDING PHYSICIAN AND DOCUMENT THE NOTIFICATION AND THE RESULTS OF THE NOTIFICATION. THERE IS NO EXCEPTION TO THIS RULE. 3. Sliding Scale Insulin will be administered as prescribed. IF THE ACCUCHECK IS TOO HIGH FOR THE PRESCRIBED DOSE, THEN YOU WILL NOTIFY THE ATTENDING PHYSICIAN AS PER POLICY. AGAIN, THERE IS NO EXCEPTION TO THIS RULE... Physician and Family Notification: 1. Licensed Nurses will notify Physician's and families/responsible parties of change in Resident condition. This is a federal requirement and not up for discussion. Not only is it a federal requirement, it is required of you by the Nurse Practice Act that you document the notification... Accountability: All Licensed Nurses will be held accountable for their actions or inactions... bad care is stopping, apathy is stopping..." Review of the June 2009 Consultant Pharmacist's Monthly Report documented "...Inservice on medication pass...insulin...Things to address: Sliding scale insulin scheduled before meals should not be given more than thirty minutes before a meal. Please make sure times of administration on MARs (Medication Administration Record) are consistent with meal times..." A memorandum attached to the report to "Nursing Staff" dated 6/3/09 documented, "...Subject: Time of Insulin Administration... Please make sure that the sliding scale regular insulin ordered before meals is not given more than thirty minutes before scheduled meal times. On the June MARs there are several insulin doses charted as given at 4PM which would be more than thirty minutes before the evening meal trays come out. Please wait to give the insulin until meal trays will be out within thirty minutes. If a meal tray is late then you must give a snack to a resident who has already received insulin. This also applies to all insulin mixtures that contain regular insulin (e.g. (for example) [MEDICATION NAME] 70/30 and [MEDICATION NAME] 70/30)." Review of the facility's "INSULIN" pharmacy inservice dated 6/8/09 documented "...Rapid acting insulins - [MEDICATION NAME], Humalog, [MEDICATION NAME] - need to be given 5- (to) 15 minutes prior to food... ALWAYS specify the insulin to be used on the sliding scale when you write the order..." Review of the facility's "INSULIN ADMINISTRATION TIMES" documented "...Rapid-acting: [MEDICATION NAME], Humalog, [MEDICATION NAME] Resident must have meal tray or snack within 10-15 minutes, or physician can order after meal administration... Short-acting: Regular ([MEDICATION NAME]) Resident must have a meal tray or snack within 30 minutes..." During an interview with the Consultant Pharmacist on 8/12/09 at 8:35 AM, the Consultant Pharmacist stated that had identified a problem with insulins around the first of June 2009. The Consultant Pharmacist stated that during the inservice she did in June 2009, she had told the facility staff that "...the insulin times should be changed according to meals (times)...Told them AC (before meals) should be scheduled at meal times...can't give (insulin) one hour before the meals...go by the normal med times..." Insulin dosage times were not changed per the pharmacy recommendation/ inservice to correspond to the individual resident's meal times until after the Survey team identified the problem and notified the facility on 8/5/09. Review of a July 2009 inservice provided by the facility on "Documentation" documented "...Accuchecks and Glucose Documentation: All Licensed Nurses will utilize the orange Glucose monitoring form. The Licensed Nurse will observe the stated ranges and notify the attending Physician when the glucose is outside the prescribed range. There is no exception to this and any offender will be reprimanded, leading to termination for repeat offenders. The Licensed Nurse will document the MD notification on the back of the glucose monitoring form and will also document the MD response..." 3. Review of the facility "Dining Times" documented "...Dinner... 4:50 PM North ...5:00 PM East 1 ...5:15 PM West Assist...5:20 PM Main... 5:30 PM West Hall... 5:45 PM East Hall... 6:00 PM East 2..." During an interview in the conference room on 8/12/09 at 10:15 AM, the Certified Dietary Manager (CDM) was asked what the diabetic diet consists of. The CDM stated, "...get a consistent carb (carbohydrate) diet... consistent amount of carbs per day... get the same thing as everyone else... desserts...may get fruit instead... depends on the carb count..." 4. Review of the "MED-PASS" provided by the American Society of Consultant Pharmacists for typical dosing administration related to meals documented "...Humalog...15 minutes before or immediately after [MEDICATION NAME]...5-10 minutes before meals... [MEDICATION NAME] R (regular) [MEDICATION NAME] R...30 minutes before [MEDICATION NAME] 70/30 (70% [MEDICATION NAME] insulin/30% Regular insulin)..." 5. Medical record review for Resident #20 documented an admitted 2/10/09 with [DIAGNOSES REDACTED]. Review of the physician's order initiated 2/10/09 documented "...ACCUCHECKS BEFORE MEALS AND AT BEDTIME ...6AM...11AM...4:30AM...8PM... SLIDING SCALE...150 - 200 = (amount of insulin to be administered) 2 UNITS...201 - 250 = 4 UNITS...251 - 300 = 6 UNITS...301 - 350 = 8 UNITS...351 - 400 = 10 UNITS...>400 = 12 UNITS..." Review of Resident #20's BS flow sheet for May 2009 documented 124 opportunities for BS to be checked. The top of the May 2009 flow sheet for SSI documented "...Call MD if BS 400 Chart on Back..." There were 37 opportunities that there was no documentation that a BS was obtained. There were 12 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 5/8/09 at 11:00 AM - BS was (=) 231, Insulin given = 0, correct dose = 4 units (U). b. 5/8/09 at 4:30 PM - BS = 323, Insulin given = 4, correct dose = 8 U. c. 5/12/09 at 6:00 AM - BS = 160, Insulin given = 0, correct dose = 2 U. d. 5/12/09 at 11:00 AM - BS = 294, Insulin given = 0, correct dose = 6 U. e. 5/13/09 at 6:30 AM - BS = 156, Insulin given = 0, correct dose = 2 U. f. 5/13/09 at 11:00 AM - BS = 310, Insulin given = 0, correct dose = 8 U. g. 5/14/09 at 6:30 AM - BS = 159, Insulin given = 0, correct dose = 2 U. h. 5/14/09 at 11:00 AM - BS = 255, Insulin given = 0, correct dose = 6 U. i. 5/18/09 at 11:00 AM - BS = 193, Insulin given = 0, correct dose = 2 U. j. 5/19/09 at 11:00 AM - BS = 394, Insulin given = 0, correct dose = 10 U. k. 5/20/09 at 6:30 AM - BS = 224, Insulin given = 0, correct dose = 4 U. l. 5/29/09 at 4:00 PM - BS = 366, Insulin given = 8, correct dose = 10 U. The administration of the wrong doses of insulin resulted in significant medication errors. The top of Resident #20's May 2009 flow sheet for SSI documented "...Call MD if BS 400 Chart on Back (facility protocol)..." There were 5 documented BS that were below 60 as follows: a. 5/5/09 at 6:30 AM - BS = 54. b. 5/8/09 at 6:30 AM - BS = 42. c. 5/18/09 at 6:30 AM - BS = 37. d. 5/19/09 at 6:30 AM - BS = 40. e. 5/22/09 at 6:30 AM - BS = 50. There was no documentation of interventions put in place for low BS, there was no documentation of any follow-up on the low BS and there was no documentation the physician was notified of these low blood sugars. There were 6 documented BS that were above 400 with no documentation that the BS was rechecked, and no documentation that the physician was notified. The BS were as follows: a. 5/8/09 at 8:00 PM - BS = 413. b. 5/11/09 at 4:00 PM - BS = 430. c. 5/13/09 at 8:00 PM - BS = 404. e. 5/14/09 at 8:00 PM - BS = 434. f. 5/20/09 at 4:00 PM - BS = 460. g. 5/28/09 at 4:00 PM - BS = 405. Review of Resident #20's BS flow sheet for June 2009 documented 120 opportunities for BS to be checked. There were 10 opportunities that there was no documentation that a BS was obtained. There were 16 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 6/5/09 at 9:00 PM - BS = 123, Insulin given = 2, correct dose = 0 U. b. 6/9/09 at 6:30 AM - BS = 188, Insulin given = 0, correct dose = 2 U. c. 6/12/09 at 11:00 AM - BS = 144, Insulin given = 2, correct dose = 0 U. d. 6/15/09 at 6:30 AM - BS = 247, Insulin given = 0, correct dose = 4 U. e. 6/15/09 at 12:00 Noon - BS = 379, Insulin given = 8, correct dose = 10 U. f. 6/15/09 at 5:00 PM - BS = 350, Insulin given 10, correct dose 8 U. g. 6/16/09 at 6:30 AM - BS = 393, Insulin given 0, correct dose 10 U. h. 6/17/09 at 6:30 AM - BS = 184, Insulin given 0, correct dose 2 U. i. 6/18/09 at 6:30 AM - BS = 297, Insulin given 0, correct dose 6 U. j. 6/19/09 at 6:30 AM - BS = 184, Insulin given 0, correct dose 2 U. k. 6/20/09 at 6:30 AM - BS = 255, Insulin given 0, correct dose 6 U. l. 6/23/09 at 6:30 AM - BS = 333, Insulin given 0, correct dose 8 U. m. 6/24/09 at 6:30 AM - BS = 315, Insulin given 0, correct dose 8 U. n. 6/25/09 at 6:30 AM - BS = 207, Insulin given 0, correct dose 4 U. o. 6/25/09 at 10:00 PM - BS = 291, Insulin given 4, correct dose 6 U. p. 6/27/09 at 6:30 AM - BS = 233, Insulin given 0, correct dose 4 U. The administration of the wrong doses of insulin resulted in significant medication errors. The top of Resident #20's June 2009 flow sheet for SSI documented "...Call MD if BS 400 Chart on Back (facility protocol)..." There were 3 documented BS that were below 60 with no documentation of interventions taken to bring the BS up, and no documentation that the physician was notified. The 3 BS were as follows: a. 6/5/09 at 6:30 AM - BS = 50. b. 6/6/09 at 11:00 AM - BS = 56. c. 6/6/09 at 5:00 PM - BS = 56, no BS obtained at 9:00 PM. There were 9 documented BS that were above 400 with no documentation that the BS was rechecked, and no documentation that the physician was notified. The BS were as follows: a. 6/4/09 at 9:00 PM - BS = 410. b. 6/10/09 at 5:00 PM - BS = 495. c. 6/11/09 at 9:00 PM - BS = 441. d. 6/14/09 at 5:00 PM - BS = 456, no BS obtained at 9:00 PM. e. 6/16/09 at 5:00 PM - BS = 407. f. 6/16/09 at 9:00 PM - BS = 434. g. 6/18/09 at 5:00 PM - BS = 405. h. 6/22/09 at 5:00 PM - BS = 500, no BS obtained at 9:00 PM. i. 6/30/09 at 5:00 PM - BS = 422. Review of Resident #20's physician's recertification orders dated 7/1/09 documented "[MEDICATION NAME] R...9 UNITS SQ WITH LUNCH... [MEDICATION NAME] 70-30...22 UNITS...EVERY MORNING..." A telephone order dated 7/1/09 documented "...Give Regular insulin 6 units before supper...Cont. (continue) sliding scale insulin per protocol for accuchecks..." A physician's progress note dated 7/1/09 documented "...Accucheck low (86) fasting but high rest of time. Will (decrease) [MEDICATION NAME] & add fixed dose of insulin..." A progress noted dated 7/22/09 documented "...BGL (blood glucose level) OOC. (out of control) Will ^ 7/30 insulin to 32 units... Cont. Abx (antibiotics)..." A telephone order dated 7/22/09 documented "...Increase morning 70/30 (insulin) to 32 units Continue insulin c (with) meals and basal insulin s (without) change..." A physician's progress note dated 7/27/09 documented "...Pt (patient) sent to ED (Emergency Department) for dehydration... Na (Sodium) 146..." A telephone order dated 7/28/09 documented "... (change) Regular Insulin at Lunch and Dinner to 10 units...(change) SSi to Standard Sliding Scale..." A telephone order dated 7/30/09 documented "...Cont. using standard sliding scale & hold all scheduled insulins until further notice..." A telephone order dated 7/31/09 documented "...Insulin 70/30 32 units at breakfast... [MEDICATION NAME] 8 units at bedtime... Hold above & scheduled insulin if pt does not eat... Regular insulin 9 units at lunch... Regular insulin 6 units at supper...Do accu (check) TID (three times a day)..." Review of Resident #20's BS flow sheet for July 2009 documented 123 opportunities for BS to be checked. The top of the July 2009 flow sheet for SSI documented "...Call MD if BS 400 Chart on Back..." There were 4 opportunities that there was no documentation that a BS was obtained. There were 12 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 7/2/09 at 9:00 PM - BS = 329, Insulin given 0, correct dose 8U. b. 7/4/09 at 6:00 AM - BS = 128, Insulin given 2, correct dose 0U. c. 7/4/09 at 9:00 PM - BS = 250, Insulin given 6, correct dose 4U. d. 7/5/09 at 9:00 PM - BS = 200, Insulin given 4, correct dose 2U. e. 7/6/09 at 9:00 PM - BS = 112, Insulin given 2, correct dose 0U. f. 7/12/09 at 6:00 AM - BS = 137, Insulin given 2, correct dose 0U. g. 7/19/09 at 6:00 AM - BS = 139, Insulin given 2, correct dose 0U. h. 7/19/09 at 9:00 PM - BS = 300, Insulin given 8, correct dose 6U. i. 7/24/09 at 6:00 AM - BS = 226, Insulin given 0, correct dose 4U. j. 7/24/09 at 4:30 PM - BS = 194, Insulin given 4, correct dose 2U. k. 7/25/09 at 6:00 AM - BS = 209, Insulin given 0, correct dose 4U. l. 7/27/09 at 4:00 PM - BS = 135, Insulin given 2, correct dose 0U. The administration of the wrong doses of insulin resulted in significant medication errors. Review of Resident #20's BS done on 7/29/09 at 6:30 AM, documented a BS of 68, and the resident was given 32 units of [MEDICATION NAME] 70/30. Review of the breakfast meal times for Resident #20 documented the meal trays come to the East hall beginning at 7:50 AM. Review of the nurse's note dated 7/29/09 at 9:58 AM, documented "...Called to room per CNA (Certified Nursing Assistant); Resident observed sweating, tongue hanging out mouth & unresponsive. BS checked reading "LO" oral gluco ([MEDICATION NAME]) given ^ (increased) BS to 20. IM gluco given ^ BS to 74; MD notified of results said to hold all insulins except SSI... Call back in 1 hr (hour) c (with) BS results..." Review of a physician's progress note dated 7/29/09 at 2:45 PM, documented "...Glucose < 20 this AM...did not eat after 32 units 70/30 (insulin) this AM. Will (decrease) insulin..." The administration of 32 units of [MEDICATION NAME] 70/30 insulin with a low blood sugar of 68 without being given any food resulted in a significant medication error and placed Resident #20 in immediate jeopardy. According to the "MED-PASS" provided by the American Society of Consultant Pharmacists, the onset of [MEDICATION NAME] 70/30 is "30 min (minutes)... Give approximately 30 minutes before meal. Each dose targets post-prandial blood sugars as well as basal insulin requirements..." The breakfast meal was not received for one hour and 20 minutes after the fast acting insulin was administered rather than the thirty minutes recommended. The resident displayed the above documented life-threatening symptoms with a blood sugar of less than 20. Observations in Resident #20's room on 8/12/09 at 8:15 AM, revealed Resident #20 had just gotten his breakfast tray and was being fed a pureed diet by a CNA. On 7/16/09 at 12:00 PM Resident #20's BS was 52. There was no documentation of any intervention taken to bring the BS up, and no documentation that the physician was notified of the low BS. The BS on 7/11/09 at 6:00 AM was 69. The resident was given 22 units of [MEDICATION NAME] 70/30 and there was no documentation that the resident ate anything. There were 6 documented BS that were above 400 with no documentation that the BS was rechecked, and no documentation that the physician was notified. The BS were as follows: a. 7/5/09 at 4:45 PM - BS = 404. b. 7/10/09 at 4:30 PM - BS = HI. c. 7/13/09 at 4:00 PM - BS = 473. d. 7/15/09 at 4:00 PM - BS = 429. e. 7/18/09 at 4:00 PM - BS = 408. f. 7/21/09 at 4:00 PM - BS = 403. Review of Resident #20's BS flow sheet for 8/1/09 through 8/10/09 at 11:45 AM, documented 38 opportunities for BS to be checked. The top of the August 2009 flow sheet for SSI documented "...Call MD if BS 400 Chart on Back..." There were 2 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 8/1/09 at 10:00 PM - BS = 424, Insulin given 0, correct dose 12U. b. 8/2/09 at 6:00 AM - BS = 215, Insulin given 6, correct dose 4U. The administration of the wrong doses of insulin resulted in significant medication errors. Review of the facility "Ordering and Receiving Medications" documented "...New medications, except for emergency or "stat" (now) medications, are ordered as follows...If needed before the next regular delivery, fax/phone the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery... "Stat" and emergency medications are ordered as follows... During regular pharmacy hours, the emergency or "stat" order is telephoned and faxed to the pharmacy immediately upon receipt. Such medications are delivered and administered within a timely manner... Emergency/STAT medication orders when medication is available in the emergency kit: From the emergency kit, remove the appropriate number of doses to be administered prior to the next regularly scheduled pharmacy delivery..." Review of a physician's telephone order for Resident #20 dated 7/30/09 at 8:25 AM, documented "[MEDICATION NAME] 1mg/kg (milligram per kilogram) IV (intravenous) X (times) 1 (one)..." A telephone order dated 7/31/09 at 3:30 PM, documented "..[MEDICATION NAME] ([MEDICATION NAME]) 1mg/kg at 11:00 daily X 10 days... Start 8/1/09... Start (after Gent ([MEDICATION NAME]) trough drawn)... [MEDICATION NAME] (lab) trough tomorrow (8/1/09 at 11:00...call result to (named MD)..." A telephone order dated 7/31/09 at 3:35 PM, documented [MEDICATION NAME] peak (lab) Monday 8/3/09 1 hour after [MEDICATION NAME] IV completed..." A telephone order dated 8/1/09 at 6:04 PM, documented "...Initiate 1st (first) dose of [MEDICATION NAME]" Review of a laboratory report dated 8/1/09 for Resident #20 documented [MEDICATION NAME] trough result "0.3". Review of the nurses' note date 8/1/09 at 6:05 PM, documented "...(named MD) notified of trough ([MEDICATION NAME]) report 0.3...Inst. (instructed) start [MEDICATION NAME]" The note dated 8/1/09 at 8:25 PM, documented "...(named MD) notified Gent. ([MEDICATION NAME]) did not arrive from pharmacy...MD order to change all previous [MEDICATION NAME] dose times & labs...Notify MD on call when [MEDICATION NAME] arrives & is started. Will give MD orders for further does (doses) & labs. at that time. Call lab results when obtained..." Review of a physician's telephone order for Resident #20 dated 8/1/09 at 8:25 PM, documented "...DC (discontinue) all previous [MEDICATION NAME] times & Give IV [MEDICATION NAME] 1mg/kg dose as soon as it arrives from pharmacy..." A telephone order dated 8/2/09 at 12:15 AM, documented Administer [MEDICATION NAME] 75mg/100ml (milligrams per milliliter) NS (normal saline) per IVPB (IV piggyback) now d/t (due to) arrival from pharmacy..." Review of Resident #20's Medication Administration Record [REDACTED]. Review of the MAR for August 2009 documented the next dose of [MEDICATION NAME] was not given until 12:00 Midnight on 8/2/09. During an interview with the Consultant Pharmacist (CP) in the conference room on 8/12/09 at 8:35 PM, the CP was asked when the pharmacy receives an order for [REDACTED]. The CP brought a written statement that documented, "...Order faxed to pharmacy and also called to pharmacy 9:41 AM... (named Pharmacist) gave instructions of mixing for IV administration. Med (medication) was taken from the emergency kit (at the facility)...8/1 (8/1/09) Called to on-call pharmacist 9:26 PM...Pharmacy courier called at 10:03 PM...Medication delivered to (named facility) 11:51 PM...Pharmacy sent following: 7/31...Billed to Emergency Kit...8/1...#3 (doses) ...8/3...#3...8/5...#2... order changed to IM (intramuscular) 8/5...#5..." During a telephone interview with Resident #20's attending physician on 8/11/09 at 11:45 AM, he stated "...there was an issue with getting [MEDICATION NAME] but, I'm sure you've see that..." Observations in Resident #20's room on 8/12/09 at 8:15 AM, revealed the resident was served a pureed diet of eggs, sausage, oatmeal, and bread pudding. During a telephone interview with Resident #20's attending physician on 8/11/09 at 11:45 AM, the MD was asked if he would expect the staff to give the scheduled doses of insulin if the BS were in the 60's or 70's. He stated, "...it would be okay, if he (resident) eats..." The MD further stated "...issues with the (BS) logs being completed... blanks... there is a system's problem..." Nurse #14 failed to hold Resident #20's scheduled dose of [MEDICATION NAME] 70/30 (70 percent (%) NPH - long acting insulin, and 30% Regular insulin - short acting) 32 units after obtaining a BS of 68 on 7/29/09 at 6:30 AM. Resident #20's scheduled breakfast time is 7:50 AM, an hour and 20 minutes after the insulin was given. There was no documentation that the resident was given a snack at the time the insulin was administered, and no documentation of follow-up monitoring of the resident's condition. This resulted in immediate jeopardy when the resident did not eat breakfast and was found unresponsive at 9:30 AM with a BS reading of "LO (below 20)". The facility's staff failure to consistently administer the wrong doses of insulin, failure to follow interventions, document follow-ups and failure to notify the physician of low and elevated BS levels placed all diabetic residents at risk to their safety and wellbeing. 6. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated for 4/6/09, 5/11/09, 6/2/09 and 7/5/09 documented, "ACCUCHECKS DAILY" and no orders for insulin to be administered. Review of the blood sugar flow sheet for April 2009 recorded 30 opportunities for BS to be checked. There were 8 doses of insulin given. a. 4/3/09 at 6:00 AM - BS = 164, Insulin given = 2 U, no SSI ordered. b. 4/10/09 at 6:00 AM - BS = 177, Insulin given = 2 U, no SSI ordered. c. 4/12/09 at 6:00 AM - BS = 181, Insulin given = 2 U, no SSI ordered. d. 4/16/09 at 6:00 AM - BS = 164, Insulin given = 2 U, no SSI ordered. e. 4/23/09 at 6:00 AM - BS = 157, Insulin given = 2 U, no SSI ordered. f. 4/24/09 at 6:00 AM - BS = 184, Insulin given = 2 U, no SSI ordered. g. 4/28/09 at 6:00 AM - BS = 164, Insulin given = 2U, no SSI ordered. h. 4/30/09 at 6:00 AM - BS = 169, Insulin given = 2 U, no SSI ordered. The administration of insulin with no physician's order resulted in significant medication errors. Review of the the blood sugar flow sheet for May 2009 recorded 31 opportunities for BS to be checked. There were 14 doses of insulin given. a. 5/3/09 at 6:00 AM - BS =178, Insulin given = 2 U, no SSI ordered. b. 5/6/09 at 6:00 AM - BS = 191, Insulin given = 2 U, no SSI ordered. c. 5/10/09 at 6:00 AM - BS = 151, Insulin given =2 U, no SSI ordered. d. 5/11/09 at 6:00 AM - BS = 189, Insulin given = 2 U, no SSI ordered. e. 5/13/09 at 6:00 AM - BS =162, Insulin given = 2 U, no SSI ordered. f. 5/16/09 at 6:00 AM - BS =164, Insulin given = 2 U, no SSI ordered. g. 5/17/09 at 6:00 AM - BS = 171, Insulin given = 2 U, no SSI ordered. h. 5/18/09 at 6:00 AM - BS = 200, Insulin given = 2 U, no SSI ordered. i. 5/20/09 at 6:00 AM - BS = 162, Insulin given = 2 U, no SSI ordered. j. 5/22/09 at 6:00 AM - BS = 160, Insulin given = 2 U, no SSI ordered. k. 5/24/09 at 6:00 AM - BS =167, Insulin given = 2 U, no SSI ordered. l. 5/25/09 at 6:00 AM - BS = 188, Insulin given = 2 U, no SSI ordered. m. 5/27/09 at 6:00 AM - BS = 186, Insulin given = 2 U, no SSI ordered. n. 5/30/09 at 6:00 AM - BS = 164, Insulin given = 2 U, no SSI ordered. The administration of insulin with no physician's order resulted in significant medication errors. Review of the blood sugar flow sheet for June 2009 recorded 30 opportunities for BS to be checked. There were 10 doses of insulin given. a. 6/3/09 at 6:00 AM - BS =166, Insulin given = 2 U, no SSI ordered. b. 6/5/09 at 6:00 AM - BS = 168, Insulin given = 2 U, no SSI ordered. c. 6/12/09 at 6:00 AM - BS = 162, Insulin given = 2 U, no SSI ordered. d. 6/14/09 at 6:00 AM - BS = 166, Insulin given = 2 U, no SSI ordered. e. 6/19/09 at 6:00 AM - BS = 154, Insulin given = 2 U, no SSI ordered. f. 6/21/09 at 6:00 AM - BS = 191, Insulin given = 2 U, no SSI ordered. g. 6/22/09 at 6:00 AM - BS = 156, Insulin given = 2 U, no SSI ordered. h. 6/24/09 at 6:00 AM - BS = 152, Insulin given = 2 U, no SSI ordered. i. 6/28/09 at 6:00 AM - BS = 150, Insulin given = 2 U, no SSI ordered. j. 6/29/09 at 6:00 AM - BS 185, Insulin given = 4 U, no SSI ordered. The administration of insulin with no physician's order resulted in significant medication errors. 7. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's recertification order dated 6/3/09 documented, "[MEDICATION NAME] R 100 UNITS/ML (milliliter) AS DIRECTED ACCORDING TO SLIDING SCALE . SLIDING SCALE 401 = 12 UNITS, RECHECK IN 2 HOURS AND IF STILL > 401, CALL MD..." Review of the Accucheck/Insulin Log documented the 6/4/09 at 5:00 PM - BS was 150 with no insulin given, the correct insulin dose to be administered was 2U. The failure to administer insulin as ordered resulted in a significant medication error. 8. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order initiated 1/1/09 documented "...ACCUCHECKS BEFORE MEALS AND AT BEDTIME ...6AM...11AM...4:30 PM...9PM... SLIDING SCALE (REGULAR)...150 - 200 = 4 UNITS...201 - 250 = 6 UNITS...251 - 300 = 8 UNITS...301 - 350 = 10 UNITS...351 - 400 = 12 UNITS...401 - 450 = 14 UNITS...> 450 = 16 UNITS...CALL MD FOR BS >450..." Review of the BS flow sheet for May 2009 recorded 124 opportunities for the BS to be checked. There were 6 with the wrong dose of insulin given, and the BS was not check on 5/29/09 at 9:00 PM. The BS with the incorrect SSI were as follows: a. 5/4/09 at 11:00 AM - BS = 152, Insulin given = 2, correct dose = 4U. b. 5/10/09 at 11:00 AM - BS = 158, Insulin given = 0, correct dose = 4U. c. 5/15/09 at 11:00 AM - BS = 251, Insulin given = 6, correct dose = 8U. d. 5/16/09 at 11:00 AM - BS = 169, Insulin given = 0, correct dose = 4U. e. 5/21/09 at 11 | 2014-07-01 |