| 28 |
ASBURY PLACE AT MARYVILLE |
445017 |
2648 SEVIERVILLE RD |
MARYVILLE |
TN |
37804 |
2017-07-27 |
520 |
E |
1 |
0 |
4611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the Monthly Pharmacist's Medication Regimen Review, review of facility investigations, medical record review, and interview, the facility failed to identify and address problems with errors in insulin administration, transcribing insulin orders, monitoring and documenting blood sugars, and following Physicians Orders for insulin administration for 12 residents (#1, #4, #5, #6, #7, #12, #13, #14, #16, #18, #20, and #22) of 17 residents reviewed for insulin administration, of 24 residents reviewed. The facility's failure resulted in Resident #1 receiving an overdose of 96 units of insulin and being hospitalized . 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: Medical record review, review of facility investigations, and interview, revealed on [DATE], Resident #1 had a blood sugar of 247 and 100 units of insulin was given, when only 4 units of insulin should have been administered to the resident. The resident became hypoglycemic (low blood sugar), unresponsive, was sent to the hospital, and was admitted to a Critical Care Unit on a ventilator to aid in breathing. Review of the hospital records revealed the resident had Acute [MEDICAL CONDITION] requiring mechanical ventilation and was unable to wean due to severe [MEDICAL CONDITION] (loss of brain function) and aspiration pneumonia (pneumonia caused by food or liquids in the lungs). The resident died on [DATE]. Medical record review for Residents #1, #4, #5, #6, #7, #12, #13, #14, #16, #18 #20, #22 revealed significant medication errors, unnecessary medications administered, missing documentation of blood glucose monitoring, and failure to follow Physicians orders throughout medical records. Review of the Consultant Pharmacist's Medication Regimen for January, (MONTH) and (MONTH) (YEAR) revealed documentation from the Consultant Pharmacist indicating problems with insulin errors, transcription errors, and problems with documentation of blood sugar levels. Interview with the Director of Nursing (DON) on [DATE] at 2:35 PM, in the DON's office, confirmed she received the monthly Consultant Pharmacist's Medication Regimen reports, as well as the Administrator. Continued interview confirmed the Quality Assurance (QA) members met monthly and after the critical insulin error on [DATE], it was brought to QA meeting. The DON initiated insulin education for nurses and initiated medication observation audits monthly after [DATE].We probably should have done better . The Medical Director, Administrator and Director of Nursing met monthly to discuss any pertinent problems. Interview with the Medical Director (MD) on [DATE] at 8:00 AM, by phone, confirmed the goal of QA was to look for the .etiology in errors . Continued interview confirmed there were not any pharmacy reports or major trends in insulin errors discussed in the QA meetings.I felt we were doing pretty good . Further interview confirmed the MD did not receive copies of the monthly Pharmacy Reports and the QA Team failed to identify ongoing insulin administration errors, errors in transcription of insulin orders, and lack of blood sugar monitoring. Refer to F282 (E), F309 (E), F329 (E), F333 (E), F490 (E), F501 (E), F514 (E) |
2020-09-01 |