cms_TN: 24
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 24 | ASBURY PLACE AT MARYVILLE | 445017 | 2648 SEVIERVILLE RD | MARYVILLE | TN | 37804 | 2017-07-27 | 333 | 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 Twelfth Edition, facility policy review, medical record review, review of Consultant Pharmacy Reports, and interview, the facility failed to prevent significant medication errors for 12 (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20 and #22) of 17 residents reviewed for insulin administration. The facility's failure resulted in Resident #1 receiving 96 more units of insulin than ordered. The Nursing Home Administrator (NHA), Executive Officer/Vice President of Operations, and Director of Nursing (DON) and were notified on [DATE] 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) 69th 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 . Review of the Facility Policy Medication Administration and Med Pass Schedule, revised (MONTH) (YEAR), revealed, .medications shall be administered as prescribed by the physician .If a dose seems excessive .the nurse should contact the physician .the nurse should compare the drug and dosage schedule to the resident's MAR (Medication Administration Record) and with the drug label . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident died on [DATE]. Medical record review of the Physicians Order dated [DATE] revealed .Humalog (fast acting) .Sliding Scale Insulin .Four Times Daily .Blood Sugar is 201XXX,[DATE].00 .(give) 4 units . Medical record review of the electronic Medication Administration Record [REDACTED].Humalog (insulin) 100 unit/ml (milliliter) .Four Times Daily XXX[DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE]XXX,[DATE] units . Continued review revealed on [DATE] at 9:00 PM the resident's blood sugar was 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. Review of a signed statement by LPN #1 dated [DATE], revealed the LPN was scheduled to work at the facility on [DATE] from 7:00 PM to 7:00 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 30 (below 70 considered low). 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 ) Further review revealed the resident was sent to the ER. Continued review revealed the EMS (Emergency Medical Service or Ambulance) started an IV on the resident and the resident was taken to the hospital. Review of an EMS record for Resident #1 dated [DATE], revealed at 6:00 AM, .Unresponsive .Blood glucose reading/level; low comments: 30 .Upper Right Lung Rhonchi (abnormal breath sound): Upper Left Lung Rhonchi; Lower Right Lung; Rhonchi: Lower Left Lung; Rhonchi . Further review revealed at 6:15 AM, .Blood Glucose Reading/Level: 216 . and at 6:16 AM .Medication Administration [MEDICATION NAME] 50% Syringe 25 (25 ml of IV solution with [MEDICATION NAME] to increase blood sugar) .Intravenous; Result after improved .Blood Glucose Reading/Level: 130 .Glascow Coma Scale (scale to detect level of consciousness) .6 (below 8 indicates comatose) .Respiratory Effort: Labored . Further review revealed, .Altered Mental Status and [DIAGNOSES REDACTED] (low blood sugar) .Pt (patient) was found unresponsive with low blood sugar .Then activated 911. Pt found unconscious and unresponsive .Upon arrival to destination (hospital) there is no improvement in his condition . Review of a Clinical Note dated [DATE] at 6:25 AM revealed Insulin dose is listed incorrectly, 100 units were given. On call Dr (physician) was called; orders were to start IV, if IV can't be started, then send to ER .Sent to ER. Last blood sugar 215 at 5:45 am . Phone interview with LPN #1 on [DATE] at 6:55 PM, confirmed, LPN #1 did not start an IV because she was not IV certified. Further interview confirmed she did not ask for help. Review of a Clinical Note dated [DATE] at 6:39 AM, reveaIed Instant Glucose given. Chocolate pudding and orange (juice) given. Review of a Medication Error Report dated [DATE] revealed CS (blood sugar) - 247 at 9 PM, Agency nurse Administered 100 units of Humalog vs (versus) the ordered 6 units (4 units per the MAR) .Sent to ER, admitted to CCU (Critical Care Unit) on vent (ventilator to aid in breathing) . Medical record review of a critical care progress note dated [DATE], from the hospital, revealed, .Acute [MEDICAL CONDITION]: Requiring mechanical ventilation day 15. Unable to wean due to severe [MEDICAL CONDITION] (abnormal brain function), apnea (temporarily stop breathing) .Aspiration pneumonia (lung infection after inhaling food) . Medical record review of a Medicine Progress Report dated [DATE], from the hospital, revealed .Patient remains intermittently alert but totally unresponsive to voice. He opens his eyes, though he does not track movement . Interview with the Administrator and Director of Nursing (DON) on [DATE] at 4:30 PM, in the DON's office, confirmed LPN #1 was an agency nurse that was working at the facility on [DATE] night shift. Further interview confirmed the LPN administered 100 units of insulin to Resident #1 in error. Interview with the Medical Director on [DATE] at 10:35 AM, in the conference room, confirmed LPN #1 made a significant medication error. Continued interview confirmed she directed the LPN to monitor the resident closely after the insulin overdose, but at the time the blood sugar was maintained. Further interview confirmed the next call she received from LPN #1 was early morning and the blood sugar was low. The Physician instructed the LPN to follow the hypoglycemic protocol, if the resident was cooperative to administer the [MEDICATION NAME], start an IV, and if unable to start the IV, to send the resident to the ER. Continued interview confirmed the hypoglycemic episode of Resident #1 could have led to the resident becoming unstable. Interview with LPN #1 on [DATE] at 6:55 PM, by phone, revealed she worked night shift on [DATE]. Continued interview confirmed she did administer 100 units of insulin to Resident #1 by error. Continued interview confirmed .I read the dosage wrong . Continued interview confirmed the LPN gave the 100 units of insulin at around 9 (9:00) PM; the resident's blood sugar was 237 at that time. Further interview confirmed she knew something was not right because the resident was sleeping hard .couldn't wake him up .trying to give him pudding and orange juice . Continued interview confirmed she went back to check the insulin order and realized the error (unsure of what that time was). Further interview confirmed LPN #1 did not start an IV because she was not IV certified and she did not ask for help. Medical record review revealed Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated [DATE] revealed .Humalog .sliding scale .Four Times Daily Starting [DATE] .Blood Sugar is 301XXX,[DATE].00 (give) 8-units . Continued review revealed on [DATE] at 5:30 PM the blood sugar was 310 and 6 units was given when 8 units should have been administered to the resident. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the Physician's Orders were not followed. Medical record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .[MEDICATION NAME] R .TID (three times daily) .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the eMAR. Further review revealed on [DATE] the blood sugar was 214 and 6 units of insulin was given, the dosage for the ,[DATE] range on the eMAR. Medical record review of the facility's Sliding Scale A parameters dated [DATE] revealed, XXX,[DATE] give 6 units . Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID .Scale A .Blood Sugar is ,[DATE] give 4 units .Blood Sugar is ,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] R U-100 100 unit/ml .Three Times Daily Starting [DATE] .Blood Sugar is 151XXX,[DATE].00 (give) 4 units .Blood Sugar is 251.00- 300.00 (give) 6 units . Continued review revealed no sliding scale for blood sugar results of ,[DATE] on the EMAR. Further review revealed the following: [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 PM-blood sugar ,[DATE] units of insulin (range not indicated on eMAR) [DATE] at 9:00 AM-blood sugar ,[DATE] units of insulin (4 units ordered) Interview with LPN #11 on [DATE] at 1:45 PM, in the 300 nurse's station, confirmed she failed to follow the Physician's Order for the sliding scale insulin. Interview with LPN #10 on [DATE] at 4:05 PM, by phone confirmed the insulin administration could have been an error. Further interview confirmed she was not instructed how to enter orders in the electronic record by order set and she put the insulin order in manually. Continued interview confirmed she was not aware she made an error while entering the insulin order on Resident #6 on [DATE] when she administered the insulin. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .Humalog 6 units bid (twice a day) with hold parameter for BS Medical record review of the Sliding Scale Insulin Order dated [DATE] revealed .Humalog .TID (three times a day) XXX,[DATE] give 0 units XXX,[DATE] give 2 units . Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 151XXX,[DATE].00 (give) 2 Units . Continued review revealed on [DATE] at 5:00 PM the blood Sugar was 183 and 4 units of insulin was given to the resident when only 2 units should have been administered. Medical record review of the (MONTH) (YEAR) eMAR with a Physicians order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 251XXX,[DATE].00 (give) 6 units . Continued review revealed on [DATE] at 8:00 AM the blood Sugar was 277 and 4 units of insulin was given to the resident when the resident should have received 6 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 0XXX,[DATE].00 0 Units .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed on [DATE] at 9:00 PM the blood Sugar was 150 and 2 units of insulin was given to the resident when the resident should not have received any insulin. Further review revealed on [DATE] at 5:00 PM, the blood sugar was 202 and 2 units of insulin was given to the resident when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units .Blood Sugar is 251XXX,[DATE].00 (give) 6 Units . Continued review revealed the following: [DATE] at 9:00 PM the Blood Sugar was 256 and 4 units given when the resident should have received 6 units. [DATE] at 12:00 PM the Blood Sugar was 236 and 6 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 217 and 2 units given when the resident should have received 4 units. Medical record review of the (MONTH) (YEAR) eMAR with a Physician's Order dated [DATE] revealed .Humalog 100 units/ml .Four Times Daily Starting [DATE] Sliding Scale Insulin .Blood Sugar is 201XXX,[DATE].00 (give) 4 units . Continued review revealed the following: [DATE] at 5:00 PM the Blood Sugar was 212 and 2 units given when the resident should have received 4 units. [DATE] at 5:00 PM the Blood Sugar was 243 and 2 units given when the resident should have received 4 units. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Sliding Scale Order dated [DATE] revealed .Scale A XXX,[DATE] give 6 units . Medical record review of the eMAR dated (MONTH) (YEAR) revealed on [DATE] at 6:00 PM the resident's blood sugar was 286 and received 4 units of insulin when the resident should have received 6 units. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed .Documentation/charting issues .This patient has an order to get Humalog insulin when blood sugar is above 200 before meals. It has been documented as given 8 times this month when blood sugar was below 200 . Medical record review of the eMAR with a Physicians Order dated [DATE] revealed .Humalog 100 unit/ml .(4 units) .before meals Starting [DATE] .Give 4 units .For Blood Sugar > (greater than) 200 . Continued review revealed on [DATE] at 12:00 PM, the blood glucose was 194 and 4 units were given to the resident when the resident should not have received any insulin. Medical record review of the (MONTH) (YEAR) eMAR revealed on [DATE] at 8:00 AM the blood sugar was 181 and 4 units were given to the resident when the resident should not have received any insulin. Further review revealed [DATE] at 12:00 PM, the blood glucose was 294 and 10 units were given to the resident when the resident should have received only 4 units. Medical record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Consultant Pharmacist's Medication Regimen Review dated [DATE]-[DATE] revealed XXX[DATE] order to increase [MEDICATION NAME] to 10 u/w/each meal (units with each) and if BG > 300 give additional 4 units .(numerous med errors may have occurred; I can't determine from eMAR when additional doses were given but BG has been > 300 on several occasions in (MONTH) and the additional dose should have been given) (notified nurse (name) to correct this date [DATE]; she stated the dose was given for BS > 300) . Medical record review of the (MONTH) (YEAR) eMAR revealed a Physcians order dated [DATE] .[MEDICATION NAME] .12 units with meals (give extra 4 units if BG > 300) . Continued review revealed the following: [DATE] 1:00 PM blood sugar 345- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 325- 12 units given (should have received 16 units) and at 5:30 PM the blood sugar was 441, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 375- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 347, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 320- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 238, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 304- 12 units given (should have received 16). Continued review revealed no documentation for a blood sugar at 5:30 PM. [DATE] 12:00 PM the blood sugar was 325, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16) and at 5:30 PM the blood sugar was 397, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 324- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 8:00 AM blood sugar 322- 12 units given (should have received 16) and at 1:00 PM the blood sugar was 358, indicating Resident #14 continued to have high blood sugar and again only received 12 units (should have received 16). Continues review revealed no documentation for the 5:30 blood sugar. [DATE] 5:30 PM blood sugar 333- 12 units given (should have received 16) and at on [DATE] at 8:00 AM the blood sugar was 216, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar 346- 12 units given (should have received 16) and at 5:30 PM the blood sugar was 429, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 323- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 232, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar 399- 12 units given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 328, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 8:00 AM blood sugar-284 - 16 units of insulin given (should have received only 12) [DATE] 5:30 PM blood sugar-,[DATE] units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 173, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-274 - 10 units of insulin given (should have received 12) and on [DATE] at 8:00 AM the blood sugar was 191, indicating Resident #14 continued to have high blood sugar. Medical record review of the (MONTH) (YEAR) eMAR revealed the following: [DATE] 1:00 PM blood sugar-330 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 169, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-307 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 205, indicating Resident #14 continued to have high blood sugar. [DATE] 1:00 PM blood sugar-327 - 12 units of insulin given (should have received 16) and at 5:30 PM the blood sugar was 187, indicating Resident #14 continued to have high blood sugar. [DATE] 5:30 PM blood sugar-316 - 12 units of insulin given (should have received 16) and on [DATE] at 8:00 AM the blood sugar was 150, indicating Resident #14 continued to have high blood sugar. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the nurses failed to follow the Physicians Orders. Continued interview confirmed when a nurse failed to follow the insulin order it put the resident at risk for harm. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .[MEDICATION NAME] 100 unit/ml .Four Times Daily Starting [DATE] .sliding scale .Blood Sugar is 150XXX,[DATE].00 1 Units .Blood Sugar is 200XXX,[DATE].00 2 Units .Blood Sugar is 300XXX,[DATE].00 4 units .Blood Sugar is > 349.00 5 units . Continued review revealed the following: [DATE] 5:00 PM blood sugar 353- 6 units insulin given (should have received 5 units) [DATE] 5:00 PM blood sugar ,[DATE] unit insulin given (should have received 2 units) [DATE] 5:00 PM blood sugar 343- 5 units insulin given (should have received 4 units) Review of the Consultant Pharmacist's Medication Regimen report dated [DATE]-[DATE] 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 eMAR dated (MONTH) (YEAR) revealed .Humalog 100 units/ml .Two Times Daily .Starting [DATE] .If BG > 200 at breakfast and supper give 4 units of Humalog . Continued review revealed the following: [DATE] 5:00 PM blood sugar 192- 4 units given (should not have received any insulin) [DATE] 8 AM blood sugar 204- 0 units (should have received 4 units) and at 5:00 PM the blood sugar was 293 indicating resident #20 continued to have high blood sugar. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the eMAR dated (MONTH) (YEAR) revealed .Humalog 100 unit/ml .(4units) .Before meals Starting [DATE] .Administer 4 units .with meals if BS > 200 . Continued review revealed the blood sugar on [DATE] at 12:00 PM was 156 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] at 8:00 AM was 85 and 4 units was given to the resident when no insulin should have been administered. Medical record review of the eMAR dated (MONTH) (YEAR) revealed the blood sugar on [DATE] was 149 and 4 units of insulin was given to the resident when no insulin should have been administered. Medical record review of the MAR indicated [REDACTED]. Humalog 100 unit/ml .(4units) .Two Times Daily Starting [DATE] .Administer 4 units .for BG > 200 . Continued review revealed the resident received insulin when it should not have been administered on: [DATE] at 9:00 AM blood sugar ,[DATE] units of insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 5:00 PM blood sugar 145- 4 units insulin given [DATE] at 9:00 AM blood sugar ,[DATE] units insulin given [DATE] at 9:00 AM blood sugar 143- 4 units insulin given Medical record review of the MAR indicated [REDACTED]. Continued review revealed on [DATE] at 8:00 AM, the blood sugar was 182 and 4 units of insulin was given when no insulin should have been administered. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician's Order dated [DATE] revealed, .Humalog (insulin) 4 (units) if blood sugar (greater than) 150 . Medical record review of Resident #5's eMAR dated [DATE] at 5:00 PM revealed a blood sugar of 100 with documentation LPN #2 gave 4 units of insulin when it was not ordered. Review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 102 with documentation LPN #3 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 130 with documentation of LPN #4 gave 4 units of insulin when it was not ordered. Medical record review of Resident #5's eMAR dated [DATE] at 8:00 AM revealed a blood sugar of 137 with documentation of LPN #2 gave 4 units of insulin when it was not ordered. Interview with LPN #8 Nurse Manager on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed LPNs #2, # 3, and #4 administered insulin when it was not needed per the physician's orders. Continued interview confirmed Resident #5's initial order had been transcribed incorrectly. Further interview confirmed RN #1 should have administered the insulin, resulting in a significant medication error. Interview with LPN #2 on [DATE] 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 documented on the (MONTH) (YEAR) MAR, revealed, .[MEDICATION NAME] (short acting insulin) .(4 units) .two times daily .Hold if BG (blood glucose) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Resident #16's MAR indicated [REDACTED]. Medical record review of Physicians Orders dated [DATE] revealed, .[MEDICATION NAME] 6 units .Hold if (blood sugar) (less than) 120 . Medical record review of Resident #16's MAR indicated [REDACTED]. Further review revealed LPN #7 did not administer 6 units of insulin. Interview with LPN #8, Nurse Manager, on [DATE] at 3:58 PM, in the DON's office, confirmed a nurse's initials on the resident's eMAR mean medication was given. Further interview confirmed not documenting a reason why a medication was held when it should have been given is considered a medication error. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's Orders dated [DATE] revealed, .Humalog 8 (units) .(with) each meal .hold if (blood sugar) (less than) 100 .if (blood sugar) (greater than) 400 give 4 (additional) (units) .check (blood sugar) (3 times a day) (before meals) . Medical record review of a Consultant Pharmacist's Medication Regimen Review for Resident #18 dated [DATE]-[DATE] revealed, .The hold parameter and order for additional units if (blood sugar) (greater than) 400 were not transcribed in the MAR . Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's Vital Sign documentation on ,[DATE] /17 at 8:05 AM revealed a blood sugar of 405. Medical record review of Resident #18's MAR indicated [REDACTED]. Medical record review of Resident #18's MAR indicated [REDACTED]. Interview with the Pharmacy Consultant on [DATE] at 1:00 PM, by phone, confirmed pharmacy reviews were conducted on every resident monthly. Further interview confirmed an electronic monthly audit was completed at that time. The pharmacist reviews the MAR indicated [REDACTED]. Continued interview confirmed it was not her responsibility to check for administration errors but if she notes errors or discrepancies she includes them in the monthly report. Interview with the Administrator on [DATE] at 8:00 AM, in the conference room, confirmed the nurses failed to follow the Physician's orders for sliding scale insulin. Further interview confirmed this put the residents at risk for potential harm. Interview with the DON on [DATE] at 2:35 PM, in the conference room, confirmed the facility had a critical insulin administration error on [DATE] and since that time had failed to recognize and assess factors placing the diabetic residents at risk for [DIAGNOSES REDACTED] or [MEDICAL CONDITION] continued interview confirmed, if a nurse administered insulin to a resident with a blood sugar of 100, and the physician's order stated hold for less than 120, it would be considered a medication error. | 2020-09-01 |