Observations:
Based on review of manufacturer's instructions, facility policies and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors, by failing to ensure that expired medications were not administered to one of seven residents reviewed (Resident 4), and failing to ensure that insulin was administered as ordered by the physician for two of seven residents reviewed (Residents 1, 7).
Findings include:
The facility's policy regarding medication administration, dated October 26, 2021, indicated that the first person to use a multi-dose medication vial was to record the date the vial was opened on an accessory label affixed for that purpose. All multi-dose vials were to be disposed of 28 days after being opened.
The manufacturer's instructions for Humulin-R (insulin - used to lower blood sugar levels), dated November 2019, revealed that Humulin-R was to be thrown away after 31 days of use, even if there was insulin left in the vial.
Physician's orders for Resident 4, dated September 6, 2021, included an order for the resident to receive 8 units of Humulin-R insulin subcutaneously (injected just under the skin) with meals.
Observations of the medication cart on the 4th floor on November 27, 2021, at 8:19 a.m. revealed that one vial of Humulin-R was labeled that it was opened on October 1, 2021, and was to be discarded on November 1, 2021. Interview with Licensed Practical Nurse 1 at that time confirmed that the vial of Humulin-R was opened on October 1, 2021, should have been discarded on November 1, 2021, but was used to administer insulin to Resident 4 during the entire month of November 2021. She stated that there was no other Humulin-R in the building for Resident 4 and that she would have to call the pharmacy for a bottle.
Interviews with the Assistant Nursing Home Administrator and Director of Nursing on November 27, 2021, at 12:35 p.m. confirmed that expired medication vials were to be removed from the medication cart, and that the medications were not to be administered to residents after they were expired.
The facility's policy regarding medication administration, dated October 26, 2021, indicated that after administering a medication, the nurse was to document the administration in the resident's Medication Administration Record (MAR).
A diagnosis record for Resident 1, dated August 15, 2021, revealed that the resident had diagnoses that included diabetes (disease that interferes with blood sugar control). Physician's orders dated October 11, 2021, included an order to increase Novolin-R (fast-acting insulin) from 28 units to 30 units subcutaneously with meals.
There was no documented evidence that Novolin-R was administered to Resident 1 with the lunch meal on October 11, 2021.
A diagnosis record for Resident 7, dated January 13, 2021, revealed that the resident had diagnoses that included diabetes. Physician's orders, dated November 22, 2021, included orders for the resident's Humulin Regular Insulin (fast-acting insulin) to be increased from 28 units to 32 units subcutaneously with meals, and for Insulin Glargine (long-acting insulin) to be increased from 12 units to 15 units subcutaneously in the morning daily.
There was no documented evidence that Insulin Glargine was administered to Resident 7 during the morning of November 22, 2021, or that Humulin insulin was administered to the resident with the lunch meal on November 22, 2021.
Interview with the Assistant Nursing Home Administrator on November 27, 2021, at 12:35 p.m. confirmed that there was no documented evidence that insulins were administered as ordered by the physician for Residents 1 and 7 on the above dates.
28 Pa. Code 211.9(a)(1)(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 12/29/2021
The following is submitted for plan of correction purposes only and should not be construed as an admission.
Replacement vial of insulin was ordered and received from Pharmacy for resident #4. Medical provider and responsible party for resident #4 were notified.
The facility notified the medical provider and responsible party on resident #1 and #7.
A baseline audit of all medication carts was conducted on November 27, 2021 by nursing administration to assure there were no other expired insulin. The facility administrative nursing staff will complete a review of all insulin orders for the past seven days to identify any omissions. Insulin administration omissions will be documented and addressed per facility policy. Medical provider and responsible party will be updated as required.
The facility updated the procedure involving monitoring for expired insulin by specifically having the night shift licensed nursing staff check all medication carts each calendar day for expired insulin. The facility will maintain a log of the medication cart insulin checks. Education on the new procedure will be completed for all licensed nursing staff, all licensed agency nursing staff, and all newly hired licensed nursing staff upon hire by the staff developer/designee.
The facility will modify the procedure involving new insulin orders by having the licensed nurse who confirmed the order communicate directly with the licensed nurse assigned to the resident in which the new insulin order was written. The facility will update its current practice to include having the Nursing Supervisor/designee monitor the electronic dashboard each shift to monitor for any missed medications. Any missed medication missed doses will be addressed at that time by the Nursing Supervisor/designee. Education on the new procedure will be completed for all licensed nursing staff, all licensed agency nursing staff, and all newly hired licensed nursing staff upon hire by the staff developer/designee.
The Director of Nursing/designee will conduct the following audits of Insulin expiration checks: Daily for two weeks, weekly for two weeks, and monthly for two months.
The Director of Nursing/designee will conduct the following audits of new Insulin orders: Daily for two weeks, weekly for two weeks, and monthly for two months.
Audit report findings will be addressed at the monthly Quality Assurance Performance Improvement meetings for review, concerns, and comments.
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