East Liverpool City Hospital

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 44810 Based on record review and interview, the faciliy failed to ensure a correct dose of insulin was administered to a patient. This affected one (Patient #2) of ten patients reviewed. Findings include: Record review revealed Patient #2 was admitted on 02/11/24 with seizure like activity. Patient #2 had a past medical history of diabetes, gastroesophageal reflux, hypertension, hyperthyroidism, and subdural hematoma. Patient #2 was discharged on 02/14/24. Review of Patient #2’s blood glucose levels revealed they fluctuated during her hospital stay. On 02/11/24 at 4:30 P.M. on admission, her blood sugar was 86 grams per deciliter (g/dL). On 02/11/24 at 10:00 P.M., her blood sugar was 103 g/dL; 02/12/24 at 6:24 A.M., 167 g/dL; 02/12/24 at 11:35 A.M., 221 g/dL; 02/12/24 at 4:00 PM, Patient #2 refused a blood sugar check; 02/12/24 at 10:13 P.M., 64 g/dL; 02/13/24 at 6:37 A.M., 117 g/dL; 02/13/24 at 11:00 A.M., 317 g/dL; 02/13/24 at 4:10 P.M., 42 g/dL; 02/13/24 at 9:54 P.M., 134 g/dL; 02/14/24 at 5:51 A.M., 111 g/dL; 02/14/24 at 11:23 A.M., 294 g/dL; and 02/14/24 at 3:36 P.M. prior to discharge, 110 g/dL. Review of physician’s order dated 02/11/24 revealed an order for Lantus (long-acting insulin) 10 units daily. Review of the medication administration record revealed Patient #2 received this daily during her stay. Review of physician’s order dated 02/11/24 revealed an order for Humalog (short acting insulin) per the sliding scale before meals and at bedtime. The sliding scale revealed if blood sugar was 0-20; 0 units of insulin; 201 to 250, three units; 251 to 350, five units; 351 to 400, seven units; and if blood sugar is greater than 400 the physician must be notified. Review of Patient #2’s blood glucose monitoring revealed on 02/13/24 at 11:00 AM, her blood sugar was 317 g/dL. Review of the medication administration record for Patient #2 revealed on 02/13/24 at 11:56 A.M. documented Patient #2 received nine units of Humalog (fast acting) insulin. The order was for five units of Humalog insulin for a blood sugar between 251 and 300. During an interview on 04/02/24 at 8:27 A.M., Staff E, an RN, stated the nursing students informed him Patient #2 had a blood sugar of 317 and they administered nine units of Humalog insulin. Staff E reported he did not go and confirm Patient #2’s sliding scale and this was right before lunch. He did not realize a medication error was ever made. Review of the facility policy titled “Medication Administration”, effective June 2023, revealed prior to administration of any medication the nurse must verify patient identification, medication name, does, route, frequency, rate of administration, and compatibility.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44810 Based on interview, record review, and policy review, the facility failed to ensure a registered nurse evaluated the nursing care for one of 10 patients reviewed (Patient #1). The census was 44. Findings include: Review of the medical record for Patient #1 revealed an admission date of 11/17/23 and a discharge date of 11/29/23. He was arrived to the emergency department on 11/17/23 with a chief complaint of possible stroke per his family. Patient #1 had a past medical history of a recent hip fracture with open repair, hypertension, and atrial fibrillation. Patient #1 was diagnosed with a transient ischemic attack and the results of his MRI were pending. He was sent to the hospital floor on 11/18/23. Review of pressure ulcer risk assessment dated 11/19/23 at 8:00 P.M. revealed Patient #1 scored a 19 which meant he was not at risk for developing pressure ulcers. Review of further documentation on 11/19/23 at 10:00 P.M., and 11/20/23, 11/21/23, 11/22/23, 11/23/23, 11/24/23, and 11/25/23 at 8:00 A.M. and 8:00 P.M. revealed he scored a 16 which put Patient #1 at risk for developing pressure ulcers. Review of a wound care nurse assessment dated 11/20/23 revealed skin interventions included offloading pillows or devices to heels. It also listed to elevate the heels while in bed. Review of the compression stocking application and removal documentation revealed they were applied on 11/18/23 and removed at 10:00 P.M. on 11/18/23. Circulation checks were completed with each application and removal. Patient #1 also had documentation reflecting this daily during his stay on 11/19/23, 11/20/23, 11/21/23, 11/22/23, 11/24/23, 11/25/23, 11/26/23, 11/27/23, 11/28/23, and 11/29/23. Review of the turn and reposition documentation for Patient #1 revealed he was turned a repositioned on 11/18/23 at 2:00 P.M. 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M. He was documented as turned and repositioned on 11/19/23, 11/20/23, 11/21/23, 11/22/23, 11/24/23, 11/25/23, 11/26/23, 11/27/23, and 11/28/23 at Midnight, 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M. He was finally documented as turned and repositioned on 11/29/23 at Midnight, 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., and 4:00 P.M. Review of heel protector application and removal documentation for Patient #1 revealed no documentation until 11/26/23 at 2:22 P.M. They were subsequently documented as applied and removed on 11/27/23, 11/28/23, and 11/29/23. Review of wound documentation for Patient #1 revealed the only wound listed for him from 11/18/23 until 11/25/23 was a right hip incision times two places. Review of wound documentation for Patient #1 dated 11/26/23 revealed he had developed a skin tear on his left shoulder and right wrist after a fall. Review of wound documentation on 11/27/23 at 10:00 A.M. for Patient #1 revealed a black unstageable pressure ulcer to his left heel that was not present on admission. The measurements for his left heel were 2.6 centimeters (cm) long by 2.1 cm wide by 0.1 cm deep. Interview on 01/09/24 at 12:46 P.M. with Staff A confirmed Patient #1 did score at risk on the pressure ulcer risk assessment and staff documented no interventions were put into place. Staff A stated that based on his risk assessment score of being at risk one of the interventions would have been to elevate his heels while in bed. Interview on 01/10/24 at 9:00 A.M. with Staff H revealed when she went to work on 11/26/23 for the night shift Staff I informed her Patient #1 had developed a pressure ulcer on his left heel. She reported she was not sure what interventions were in place before then because that was the first time she had cared for him. Interview on 01/10/24 at 9:07 A.M. with Staff I revealed on 11/26/23 around 2:00 P.M. she entered Patient #1’s room and found his daughter bathing him. She stated Patient #1’s daughter reported to her that she bathed Patient #1 daily. Staff I informed her that Patient #1 had already had a bath that morning, but she would assist her to bathe Patient #1. Staff I reported she helped his daughter remove his socks when she was called out of the room. She exited the room and was gone for approximately less than ten minutes and when she returned Patient #1’s daughter informed her that a wound was found on his left heel. Staff I then assessed the wound and notified the physician and the wound nurse. She then reported she applied heel protectors to Patient #1’s heel. She confirmed that heel protectors had not been in his room prior to her applying them and there were no extra pillows to float his heels while in bed. Staff I confirmed Patient #1’s left heel had an area of an unstageable pressure injury that was completely black from eschar with no drainage or odor. Interview on 01/10/24 at 10:00 A.M. with Staff C revealed that she was notified of Patient #1’s wound on his left heel after the staff had completed an incident report. She reported she assessed him on 11/27/23 and found it to be an unstageable pressure injury. She reported she also had the wound nurse practitioner assess the wound and he ordered heel protectors and a seat cushion from that time one. Review of the facility policy titled, Skin Integrity-Patient & Mucosal Injury, reviewed April 2023, revealed if a patient scores between a 15 and 18 on the pressure ulcer risk assessment they were considered at mild risk. Interventions for patients at mild risk included: Turning and/or repositioning every one-two hours; Protect/float heels; Maximize remobilization; Manage moisture, friction, and shear; Head of bed 30 degrees, as tolerated; Inspect under and around medical devices. This deficiency represents non-compliance investigated under Substantial Allegation OH00148757.”