cms_TN: 23
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 329 | E | 1 | 0 | 4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Physicians' Desk Reference (PDR), Brunner & Suddarth's Textbook of Medical Surgical Nursing, medical record review, review of facility investigations, interview, and review of the Consultant Pharmacists reports, the facility administered medications unnecessarily for 9 residents (#1,#5, #7, #13, #14,#16,#18, #20, #22,) of 17 residents reviewed. The facility's failure resulted in Resident #1 receiving 100 units of insulin, instead of 4 units, and being hospitalized . The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on 7/27/17 at 1:25 PM in the administrator's office, that Resident #1 received an overdose of insulin. The findings included: Review of Physicians' Desk Reference (PDR) 69 Edition, (YEAR), pg 2044 - 2045, revealed, .[DIAGNOSES REDACTED] is defined as an episode of blood glucose concentration Review of Brunner and Suddarth's Textbook of Medical Surgical Nursing Twelfth Edition, chapter 41 revealed, .Because the insulin dose required by the individual patient is determined by the level of blood glucose in the blood, accurate monitoring of blood glucose levels is essential .In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucogon (medication used to increase blood sugar) can be administered .[MEDICAL CONDITION] . (defined as) elevated blood glucose level .greater than 110 . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order dated 8/25/16 revealed .Humalog (fast-acting insulin) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201.00-250.00 .(give) 4 units . Medical record review of the Electronic Medication Administration Record [REDACTED].Humalog 100 unit/ml (milliliter) .Four Times Daily .8/26/16 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 - 4 units . Indicating the resident was to receive 4 units of Humalog insulin for a blood sugar reading of 201-250. Continued review revealed on 9/11/16 at 9:00 PM, the resident's blood sugar was 247 and 100 units of insulin was administered instead of 4 units. Medical record review of the Medication Error Report dated 9/12/16 revealed .based on CS (fingerstick lab to determine blood sugar) (blood sugar)- 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (order indicated 4 units was to be given) .Sent to ER (emergency room ), admitted to CCU (critical care unit) on vent (ventilator to assist breathing) . Review of the Emergency Medical Service or Ambulance Service (EMS) record dated 9/12/16 revealed at 6:00AM, .Unresponsive .Blood glucose reading/level; low comments: 30 (blood glucose reading was 30 with any level under 70 considered low) .Upper Right Lung Rhonci (continuous rattling lung sounds caused by obstruction or secretions): Upper Left Lung Rhonci; Lower Right Lung; Rhonci: Lower Left Lung; Rhonci . At 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM, .Medication Administration [MEDICATION NAME] 50% Syringe (intravenous solution to raise blood sugar levels) .Result after improved .Blood Glucose Reading/Level: 130 .Glasco Coma Scale GCS (neurological scale used to assess conscious state) .6 (less than 8 is considered comatose) .Respiratory Effort: Labored . Further review of the EMS record revealed, .Altered Mental Status and [DIAGNOSES REDACTED] .Pt (patient) was found unresponsive with low blood sugar .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a signed statement by Licensed Practical Nurse (LPN) #1 on 9/12/16, revealed the LPN was scheduled to work at the facility on 9/11/16 from 7 PM to 7 AM. Further review revealed she checked the resident's blood sugar at approximately 8:30 PM and it was 247. Continued review revealed .I read the (insulin order) to say 100 units of Humilin R Insulin, I gave the 100 units and continued with med pass .walked the halls and noticed my male patient/resident breathing heavily around 11:30 PM, I checked his blood sugar at this time and it was 197 .went back to check on sliding scale around 5am .checked blood sugar and (blood sugar) 30. MD (Physician) was called and ordered instant glucose .start an IV (intravenous catheter in a vein to administer fluids and medications) .and if IV can't be started to send to ER .(emergency room ) . Interview with LPN #1 on 7/17/17 at 6:55 PM, via telephone, confirmed 100 units of insulin was administered to Resident #1 in error. Further interview confirmed she .read the dosage wrong .realized 1 or 2 hours later when he was sleeping .I went back and looked at the order . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR dated (MONTH) (YEAR) with a physician's orders [REDACTED].Humalog 100 units/ml .Four Times Daily Starting 3/18/2017 Sliding Scale Insulin .Blood Sugar is 201.00-250.00 (give) 4 units . Continued review revealed on 7/10/17 at 12:00 PM, Resident #7's blood sugar was 236 and 6 units of insulin was given, 2 more units of insulin than was necessary. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .before meals Starting 04/18/2017 .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on 4/26/17 at 12:00 PM, Resident #13's blood glucose was 194 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Medical record review of the eMAR with a physician's orders [REDACTED].#13's blood glucose was 181 and 4 units were given to the resident, which was not necessary according to the physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 7/26/17 at 2:35 PM, in the conference room, confirmed nurses were expected to follow the physician's orders [REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen for Resident #14 dated 3/1/17-3/14/17 revealed .Med Occurrence-transcription discrepancy resulting in error .1/30/17 order to increase [MEDICATION NAME] (fast-acting insulin) to 10 u (units)w (with) / each meal if 'BG (blood glucose or blood sugar) > 300 give 4 additional units'. The order on the eMAR states to give 4 additional units if BG 300 on several occasions in (MONTH) and the additional doses should have been given)(notified nurse (name) to correct this date 3/13/17; she stated the dose was given for BS (blood surgar) > 300) . Medical record review of the MARs for the time period revealed documentation did not clearly indicate when the additional insulin was administered or not administered. Medical record review of a physician's orders [REDACTED].Increase [MEDICATION NAME] to 12 (u) units w (with) meals TID (3 times a day) + (plus) extra 4 u if BG > 300 . Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] 100 unit/ml .Three Times Daily Starting 5/3/17 .give 12 units with meals (give extra 4 units if BG > 300) . Continued review revealed on 6/2/17 the blood sugar was 284 and 16 units of insulin was given, 4 more units of insulin than was necessary. Interview with the DON on 7/26/17 at 2:35 PM, in the conference room, confirmed when a nurse failed to follow the insulin order, residents were at risk for potential harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen report dated 4/1/17-4/11/17 revealed .Documentation/charting issues .Humalog is only to be given when blood sugar is above 200. It was documented as given 5 times so far this month when it should have been held . Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting 2/20/217 .sliding scale .Blood Sugar is 150.00-199.00 (give) 1 Units .Blood Sugar is 200.00-249.00 (give) 2 Units .Blood Sugar is 300.00-349.00 (give) 4 units .Blood Sugar is > 349.00 (give) 5 units . Continued review revealed on 3/1/17 at 5:00 PM Resident #20's blood sugar was 353 and 6 units of insulin was given, 1 unit of insulin more than necessary, and on 3/12/17 at 5:00 PM, the resident's blood sugar was 343 and 5 units of insulin was given, 1 unit of insulin more than was necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 units/ml .Two Times Daily .Starting 4/18/17 .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed on 5/6/17 at 5:00 PM, Resident #20's blood sugar was 192 and 4 units of insulin was unnecessarily given (should not have received any insulin). Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].Humalog 100 unit/ml .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on 2/18/17 at 12:00 PM, was 156 and 4 units of insulin was given to the resident, which was unnecessary according to the physician's orders [REDACTED]. Further review revealed at 5:00 PM the blood sugar level was 94. Medical record review of the (MONTH) (YEAR) eMAR revealed the blood sugar on 3/5/17 at 8:00 AM, was 85 and 4 units of insulin was administered, which was not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Further review revealed the insulin was administered when and not necessary. Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting 4/10/2017 .Administer 4 units .for BG > 200 . Continued review revealed the following unnecessary insulin administration: 4/14/17 at 9:00 AM blood sugar 96-4 units of insulin given 4/15/17 at 9:00 AM blood sugar 155- 4 units insulin given 4/16/17 at 9:00 AM blood sugar 170- 4 units insulin given 4/20/17 at 9:00 AM blood sugar 98-4 units insulin given 4/21/17 at 5:00 PM blood sugar 156-4 units insulin given 4/23/17 at 9:00 AM blood sugar 154-4 units insulin given 4/27/17 at 5:00 PM blood sugar 145- 4 units insulin given 4/29/17 at 9:00 AM blood sugar 108-4 units insulin given 4/30/17 at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the (MONTH) (YEAR) eMAR with a physician's orders [REDACTED].#22's blood sugar was 134 and 4 units of insulin was given unnecessarily, and on 5/17/17 at 8:00 AM, the resident's blood sugar was 182 and 4 units of insulin was given unnecessarily. Interview with the Administrator on 7/26/17 at 8:00 AM, in the conference room, confirmed the nurse failed to follow the physician's orders [REDACTED]. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated 2/16/17 at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not needed. Review of Resident #5's eMAR dated 2/25/17 at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 2/26/17 at 8:00 AM revealed a blood sugar of 130 with documentation LPN #4 gave 4 units of insulin when it was not needed. Medical record review of Resident #5's eMAR dated 3/6/17 at 8:00 AM revealed a blood sugar of 137 with documentation LPN #2 gave 4 units of insulin when it was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's MAR meant medication was given. Further interview confirmed LPNs #2, #3, and #4 administered insulin when it was not needed per the physician's orders [REDACTED]. Interview with LPN #2 on 7/26/17 at 5:52 PM, via telephone, confirmed she administered insulin outside of parameters for Resident #5. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's eMAR dated 1/2/17 at 9:00 AM revealed a blood sugar of 88 with documentation LPN #5 gave 4 units of insulin when it was not needed. Medical record review of Resident #16's eMAR dated 1/3/17 at 9:00 AM revealed a blood sugar of 77 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/6/17 at 9:00 AM revealed a blood sugar of 76 with documentation LPN #5 gave 4 units of insulin that was not needed. Medical record review of Resident #16's eMAR dated 1/10/17 at 9:00 AM revealed a blood sugar of 115 with documentation LPN #6 gave 4 units of insulin that was not needed. Interview with LPN #8 Nurse Manager on 7/25/17 at 3:58 PM, in the DON's office confirmed LPN #5 and LPN #6 administered insulin when it was not necessary per physician's orders [REDACTED]. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's orders [REDACTED].Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 110 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of Resident #18's eMAR dated 4/20/17 revealed, .Humalog (8 units) .Notes .hold if below 110 If greater than 400 give 4 additional units . Medical record review of Resident #18's eMAR dated 6/30/17 at 12:00 PM revealed a blood sugar of 104 with documentation RN #1 gave 4 units of insulin when it was not needed. Medical record review of Resident #18's eMAR dated 7/2/17 at 12:00 PM, revealed a blood sugar of 100 with documentation RN #1 gave 4 units of insulin when it was not needed. Interview with LPN #8, Nurse Manager, on 7/25/17 at 3:58 PM, in the DON's office, confirmed RN #1 administered insulin when it was not indicated by the physician's orders [REDACTED]. Interview with the DON on 7/26/17 at 2:35 PM, in the DON's office, confirmed if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's orders [REDACTED]. | 2020-09-01 |