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Based on document review and interview, it was determined that the facility staff failed to maintain the clinical record consistent with the hospital policy and procedures to include all evaluations of the patient and appropriate findings for two (2) of seven (7) patients (Patients # 1 and # 5).


The findings include:

1. The medical record of Patient # 1 was reviewed on May 20 and May 21, 2019. Patient # 1 was a 23 year old who presented to the Emergency Department (ED) with complaint of hyperglycemia (500 at home about an hour prior to admission, took 9 units of humalog, finger stick blood glucose (FSBG) in triage was 362) and nausea on March 24, 2019 at 4:34 a.m.
At 4:40 a.m. Patient # 1 was placed in a room in the ED.
At 4:52 a.m. Documentation by the RN (Registered Nurse) reads "Patient reports feeling nausea and dehydrated at home. Checked BS @ home was 500 took 9 units @ home, called nurse hotline who advised to come in to ED. Hx of type 1 diabetes."
At 4:58 a.m. Orders were placed for CMP (comprehensive metabolic panel), CBC (complete blood count) with auto differential, sodium chloride 0.9% bolus 1,000 ml, and ondansetron injection 4 mg.
At 6:05 a.m. CMP results show Glucose 458.
6:15 a.m. Orders were placed for ondansetron injection 4 mg and sodium chloride 0.9% bolus 1,000 ml.
6:35 a.m. Discharge disposition selected by MD - ED Disposition set to discharge.
6:36 a.m. MD note reads in part "Patient is known insulin-dependent diabetic. [He/she] has an insulin pump. [He/she] checked blood sugar and it was over 500. [He/she] did urinate was positive for ketones. [He/she] gave [himself/herself] an additional 9 units to [his/her] insulin pump. [he/she] thinks [he/she] may have not given enough extra insulin after evening meal. [He/she] currently has no pain. [He/she] still feels somewhat nauseated."
"Diagnosis management comments" reads in part "Very nice patient. No evidence of DKA (diabetic ketoacidosis). [He/she] is very comfortable performing a sliding scale using [his/her] pump. [He/she] will monitor blood sugar closely. [He/she] has a very informed patient [he/she] returns any issues or new problems."
"Disposition" reads "Discharge."
"Diagnoses" reads "Non-intractable vomiting with nausea, unspecified vomiting type, hyperglycemia."
7:33 a.m. POC (point of care) glucose 360.
8:02 a.m. Patient discharged

An interview with Staff Member # 4 on May 20, 2019 at 1:42 p.m. revealed the following. "There was a letter received by the facility on April 10, 2019 from [Patient # 1's family]. The ED Medical Director and the ED Nurse Manager reviewed the chart [ED Medical Director's name] stated "Did briefly have DKA during stay at [facility name] but it resolved before discharge and did not have an emergent medical condition." The ED manager agreed the "nursing care was appropriate for the patient." Facility staff spoke with [Patient # 1's family] on April 11, 2019 and also sent a letter informing [him/her] of the findings."

An interview with Staff Member # 7, Endocrinologist, on May 20, 2019 at 2:30 p.m. revealed "DKA doesn't always mean a high blood glucose. If the blood glucose is high then a urine should be checked for ketones and blood work is needed to determine DKA. Blood work would include at a minimum BMP (glucose, BUN (blood urea nitrogen), creatinine, sodium, potassium, chloride, CO2 (carbon dioxide), calcium, total protein, albumin, AST (aspartate aminotransferase), alkaline phosphatase, ALT (alanine aminotransferase), total bilirubin and eGFR (estimated glomerular filtration rate), pH (potential of hydrogen), bicarb (bicarbonate), anion gap and urine for ketones. A safe discharge glucose would be at least below 300, ideally below 250 in conjunction with other normal labs."
There was no documentation in the medical record for Patient # 1 to include a pH, bicarb, anion gap and urine for ketones.

An interview with Staff Member # 9, ED Medical Director on May 21, 2019 at 9:30 a.m. revealed "[Staff Member # 10' name] identified the high blood glucose, ordered IV fluids and a metabolic panel, calculated the anion gap and determined the patient was not in DKA. The anion gap is a manual calculation (Na - chloride - CO2). Anion gap of less than 15 is ok. The physician does not always document the anion gap. Three things are required to diagnosis DKA increased blood glucose, positive ketones and pH below 7.25."
When asked if after the review of this chart did [he/she] state "the patient did briefly have DKA during stay but it resolved before discharge and did not have emergent medical condition." Staff Member # 9 stated "That was a communication error during a phone conversation."
There was no documentation in the medical record for Patient # 1 to include a pH or urine for ketones.

A review of the Medical Staff by laws (revision date April 12, 2017) provided by Staff Member # 2 on May 20, 2019 at 11:00 a.m. revealed the following. "Medical Record Content - The medical record must be sufficiently detailed to enable the practitioners responsible for the patient to provide continuing care of the patient to determine later what the patient's condition was at a specific time.
Diagnostic and Therapeutic Reports - The medical record must contain reports pertinent to care of the patient including: pathology and clinical laboratory reports; imaging studies; other diagnostic results; surgery/invasive procedures; and results of medical assessments and treatments."

A review of the facility's "DKA protocol - adult" provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m. reads in part "Initiate in Emergency Department. Diagnosis include: Blood Glucose greater than 250mg/dl; Arterial pH less than 7.25; Plasma Bicarb less than/equal to 15; Anion Gap greater that 15; and + Ketones in urine."
There was no documentation the DKA protocol was followed.

2. The medical record of Patient #5 was reviewed on 5/21/19 at various times during the day. Patient #5 was a 49 year old transferred from another hospital's emergency department and admitted to ICU at this facility on 3/28/19 with the diagnosis of diabetic ketoacidosis (DKA ).

Patient #5 was placed on DKA protocol on admission. According to the facility's DKA protocol - adult provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m., the DKA protocol consisted of the following:
1. Basic Metabolic Panel (BMP) (which is a measurement of: glucose, BUN (Blood Urea Nitrogen), creatinine, sodium, potassium, chloride, CO 2 (carbon dioxide), calcium and eGFR (Glomerular filtration rate)) every 2 hours until CO 2 is greater than or equal to 15 mmol/l (millimoles per litre) and Anion Gap (AG) is less than 12.
2. Then BMP BID (twice daily) for 2 days.
3. PO 4 (Phosphate) every 12 hours times 2 then daily for 2 days.
4. MG (magnesium) every 12 hours times 2 then daily for 2 days.
5. If the pH on initial ABGs (Arterial Blood Gases) is less than 7.25 then repeat ABGs in 2 hours.

The medical record did not contain the DKA Flowsheets.

The physician's note dated 3/28/19 at 9:44 A.M. states, "...At presentation at the emergency room she was noted to be in DKA..." There was no documentation as to what the AG was at this time.
Nursing Note dated 3/28/19 at 5:33 P.M. states, "...Gap closed on second BMP..." There was no documentation as to what the AG was.
Nursing Note dated 3/29/19 at 3:07 P.M. states, "(Name of Physician) notified that pt (Patient #5) with closed gap (AG) since 6:00 this morning..." There is no documentation as to what the AG was at that time.
Nursing Note dated 3/29/19 at 9:14 P.M. states, "GAP reopened last night after transitioning to insulin pump." There was no documentation as to what the GAP was.

Staff Member #6 (Registered Nurse, Manager ICU) was interviewed on 5/21/19 at approximately 1:00 P.M. Staff Member #6 stated, "Once the patient has had two (2) consecutive AGs of 12 or below we will begin to transition them from ICU to the floor or sometimes we have discharged from ICU. The AGs are calculate every four (4) hours and documented on the DKA Flowsheet which is scanned into the medical record upon discharge."

Staff Member #3 was interviewed on 5/21/19 at approximately 1:35 P.M. and stated, "HIM (Health Information Management) and ICU could not locate the DKA Flowsheets."

Based on document review and interview, it was determined that the facility staff failed to maintain a clinical record to include information regarding the condition of a patient for two (2) of seven (7) patients (Patients # 1 and # 5).

The findings include:

1. The medical record of Patient # 1 was reviewed on May 20 and May 21, 2019. Patient # 1 was a 23 year old who presented to the Emergency Department (ED) with complaint of hyperglycemia (500 at home about an hour prior to admission, took 9 units of humalog, finger stick blood glucose (FSBG) in triage was 362) and nausea on March 24, 2019 at 4:34 a.m.
At 4:40 a.m. Patient # 1 was placed in a room in the ED.
At 4:52 a.m. Documentation by the RN (Registered Nurse) reads "Patient reports feeling nausea and dehydrated at home. Checked BS @ home was 500 took 9 units @ home, called nurse hotline who advised to come in to ED. Hx of type 1 diabetes."
At 4:58 a.m. Orders were placed for CMP (comprehensive metabolic panel), CBC (complete blood count) with auto differential, sodium chloride 0.9% bolus 1,000 ml, and ondansetron injection 4 mg.
At 6:05 a.m. CMP results show Glucose 458.
6:15 a.m. Orders were placed for ondansetron injection 4 mg and sodium chloride 0.9% bolus 1,000 ml.
6:35 a.m. Discharge disposition selected by MD - ED Disposition set to discharge.
6:36 a.m. MD note reads in part "Patient is known insulin-dependent diabetic. [He/she] has an insulin pump. [He/she] checked blood sugar and it was over 500. [He/she] did urinate was positive for ketones. [He/she] gave [himself/herself] an additional 9 units to [his/her] insulin pump. [he/she] thinks [he/she] may have not given enough extra insulin after evening meal. [He/she] currently has no pain. [He/she] still feels somewhat nauseated."
"Diagnosis management comments" reads in part "Very nice patient. No evidence of DKA (diabetic ketoacidosis). [He/she] is very comfortable performing a sliding scale using [his/her] pump. [He/she] will monitor blood sugar closely. [He/she] has a very informed patient [he/she] returns any issues or new problems."
"Disposition" reads "Discharge."
"Diagnoses" reads "Non-intractable vomiting with nausea, unspecified vomiting type, hyperglycemia."
7:33 a.m. POC (point of care) glucose 360.
8:02 a.m. Patient discharged

An interview with Staff Member # 4 on May 20, 2019 at 1:42 p.m. revealed the following. "There was a letter received by the facility on April 10, 2019 from [Patient # 1's family]. The ED Medical Director and the ED Nurse Manager reviewed the chart [ED Medical Director's name] stated "Did briefly have DKA during stay at [facility name] but it resolved before discharge and did not have an emergent medical condition." The ED manager agreed the "nursing care was appropriate for the patient." Facility staff spoke with [Patient # 1's family] on April 11, 2019 and also sent a letter informing [him/her] of the findings."

An interview with Staff Member # 7, Endocrinologist, on May 20, 2019 at 2:30 p.m. revealed "DKA doesn't always mean a high blood glucose. If the blood glucose is high then a urine should be checked for ketones and blood work is needed to determine DKA. Blood work would include at a minimum BMP (glucose, BUN (blood urea nitrogen), creatinine, sodium, potassium, chloride, CO2 (carbon dioxide), calcium, total protein, albumin, AST (aspartate aminotransferase), alkaline phosphatase, ALT (alanine aminotransferase), total bilirubin and eGFR (estimated glomerular filtration rate), pH (potential of hydrogen), bicarb (bicarbonate), anion gap and urine for ketones. A safe discharge glucose would be at least below 300, ideally below 250 in conjunction with other normal labs."
There was no documentation in the medical record for Patient # 1 to include a pH, bicarb, anion gap and urine for ketones.

An interview with Staff Member # 9, ED Medical Director on May 21, 2019 at 9:30 a.m. revealed "[Staff Member # 10' name] identified the high blood glucose, ordered IV fluids and a metabolic panel, calculated the anion gap and determined the patient was not in DKA. The anion gap is a manual calculation (Na - chloride - CO2). Anion gap of less than 15 is ok. The physician does not always document the anion gap. Three things are required to diagnosis DKA increased blood glucose, positive ketones and pH below 7.25."
When asked if after the review of this chart did [he/she] state "the patient did briefly have DKA during stay but it resolved before discharge and did not have emergent medical condition." Staff Member # 9 stated "That was a communication error during a phone conversation."
There was no documentation in the medical record for Patient # 1 to include a pH or urine for ketones.

A review of the Medical Staff by laws (revision date April 12, 2017) provided by Staff Member # 2 on May 20, 2019 at 11:00 a.m. revealed the following. "Medical Record Content - The medical record must be sufficiently detailed to enable the practitioners responsible for the patient to provide continuing care of the patient to determine later what the patient's condition was at a specific time.
Diagnostic and Therapeutic Reports - The medical record must contain reports pertinent to care of the patient including: pathology and clinical laboratory reports; imaging studies; other diagnostic results; surgery/invasive procedures; and results of medical assessments and treatments."

A review of the facility's "DKA protocol - adult" provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m. reads in part "Initiate in Emergency Department. Diagnosis include: Blood Glucose greater than 250 mg/dl; Arterial pH less than 7.25; Plasma Bicarb less than/equal to 15; Anion Gap greater that 15; and + Ketones in urine."
There was no documentation the DKA protocol was followed.

2. The medical record of Patient #5 was reviewed on 5/21/19 at various times during the day. Patient #5 was a 49 year old transferred from another hospital's emergency department and admitted to ICU at this facility on 3/28/19 with the diagnosis of diabetic ketoacidosis (DKA ).

Patient #5 was placed on DKA protocol on admission. According to the facility's "DKA protocol - adult" provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m. the DKA protocol consist of the following:
1. Basic Metabolic Panel (BMP) (which is a measurement of: glucose, BUN (Blood Urea Nitrogen), creatinine, sodium, potassium, chloride, CO 2 (carbon dioxide), calcium and eGFR (Glomerular filtration rate)) every 2 hours until CO 2 is greater than or equal to 15 mmol/l (millimoles per litre) and Anion Gap (AG) is less than 12.
2. Then BMP BID (twice daily) for 2 days.
3. PO 4 (Phosphate) every 12 hours times 2 then daily for 2 days.
4. MG (magnesium) every 12 hours times 2 then daily for 2 days.
5. If the pH on initial ABGs (Arterial Blood Gases) is less than 7.25 then repeat ABGs in 2 hours.

The medical record did not contain the DKA Flowsheets.

The physician's note dated 3/28/19 at 9:44 A.M. states, "...At presentation at the emergency room she was noted to be in DKA..." There was no documentation as to what the AG was at this time.
Nursing Note dated 3/28/19 at 5:33 P.M. states, "...Gap closed on second BMP..." There was no documentation as to what the AG was.
Nursing Note dated 3/29/19 at 3:07 P.M. states, "(Name of Physician) notified that pt (Patient #5) with closed gap (AG) since 6:00 this morning..." There was no documentation as to what the AG was at that time.
Nursing Note dated 3/29/19 at 9:14 P.M. states, "GAP reopened last night after transitioning to insulin pump." There was no documentation as to what the GAP was.

Staff Member #6 (Registered Nurse, Manager ICU) was interviewed on 5/21/19 at approximately 1:00 P.M. Staff Member #6 stated, "Once the patient has had two (2) consecutive AGs of 12 or below we will begin to transition them from ICU to the floor or sometimes we have discharged from ICU. The AGs are calculate every four (4) hours and documented on the DKA Flowsheet which is scanned into the medical record upon discharge."

Staff Member #3 was interviewed on 5/21/19 at approximately 1:35 P.M. and stated, "HIM (Health Information Management) and ICU could not locate the DKA Flowsheets."

Based on document review and interview, it was determined that the facility staff failed to maintain the clinical record complete and consistent with hospital policy and procedures for two (2) of seven (7) patients (Patients # 1 and # 5).

The findings include:

1. The medical record of Patient # 1 was reviewed on May 20 and May 21, 2019. Patient # 1 was a 23 year old who presented to the Emergency Department (ED) with complaint of hyperglycemia (500 at home about an hour prior to admission, took 9 units of humalog, finger stick blood glucose (FSBG) in triage was 362) and nausea on March 24, 2019 at 4:34 a.m.
At 4:40 a.m. Patient # 1 was placed in a room in the ED.
At 4:52 a.m. Documentation by the RN (Registered Nurse) reads "Patient reports feeling nausea and dehydrated at home. Checked BS @ home was 500 took 9 units @ home, called nurse hotline who advised to come in to ED. Hx of type 1 diabetes."
At 4:58 a.m. Orders were placed for CMP (comprehensive metabolic panel), CBC (complete blood count) with auto differential, sodium chloride 0.9% bolus 1,000 ml, and ondansetron injection 4 mg.
At 6:05 a.m. CMP results show Glucose 458.
6:15 a.m. Orders were placed for ondansetron injection 4 mg and sodium chloride 0.9% bolus 1,000 ml.
6:35 a.m. Discharge disposition selected by MD - ED Disposition set to discharge.
6:36 a.m. MD note reads in part "Patient is known insulin-dependent diabetic. [He/she] has an insulin pump. [He/she] checked blood sugar and it was over 500. [He/she] did urinate was positive for ketones. [He/she] gave [himself/herself] an additional 9 units to [his/her] insulin pump. [he/she] thinks [he/she] may have not given enough extra insulin after evening meal. [He/she] currently has no pain. [He/she] still feels somewhat nauseated."
"Diagnosis management comments" reads in part "Very nice patient. No evidence of DKA (diabetic ketoacidosis). [He/she] is very comfortable performing a sliding scale using [his/her] pump. [He/she] will monitor blood sugar closely. [He/she] has a very informed patient [he/she] returns any issues or new problems."
"Disposition" reads "Discharge."
"Diagnoses" reads "Non-intractable vomiting with nausea, unspecified vomiting type, hyperglycemia."
7:33 a.m. POC (point of care) glucose 360.
8:02 a.m. Patient discharged.

An interview with Staff Member # 4 on May 20, 2019 at 1:42 p.m. revealed the following. "There was a letter received by the facility on April 10, 2019 from [Patient # 1's family]. The ED Medical Director and the ED Nurse Manager reviewed the chart [ED Medical Director's name] stated "Did briefly have DKA during stay at [facility name] but it resolved before discharge and did not have an emergent medical condition." The ED manager agreed the "nursing care was appropriate for the patient." Facility staff spoke with [Patient # 1's family] on April 11, 2019 and also sent a letter informing [him/her] of the findings."

An interview with Staff Member # 7, Endocrinologist, on May 20, 2019 at 2:30 p.m. revealed "DKA doesn't always mean a high blood glucose. If the blood glucose is high then a urine should be checked for ketones and blood work is needed to determine DKA. Blood work would include at a minimum BMP (glucose, BUN (blood urea nitrogen), creatinine, sodium, potassium, chloride, CO2 (carbon dioxide), calcium, total protein, albumin, AST (aspartate aminotransferase), alkaline phosphatase, ALT (alanine aminotransferase), total bilirubin and eGFR (estimated glomerular filtration rate), pH (potential of hydrogen), bicarb (bicarbonate), anion gap and urine for ketones. A safe discharge glucose would be at least below 300, ideally below 250 in conjunction with other normal labs."
There was no documentation in the medical record for Patient # 1 to include a pH, bicarb, anion gap and urine for ketones.

An interview with Staff Member # 9, ED Medical Director on May 21, 2019 at 9:30 a.m. revealed "[Staff Member # 10' name] identified the high blood glucose, ordered IV fluids and a metabolic panel, calculated the anion gap and determined the patient was not in DKA. The anion gap is a manual calculation (Na - chloride - CO2). Anion gap of less than 15 is ok. The physician does not always document the anion gap. Three things are required to diagnosis DKA increased blood glucose, positive ketones and pH below 7.25."
When asked if after the review of this chart did [he/she] state "the patient did briefly have DKA during stay but it resolved before discharge and did not have emergent medical condition." Staff Member # 9 stated "That was a communication error during a phone conversation."
There was no documentation in the medical record for Patient # 1 to include a pH or urine for ketones.

A review of the Medical Staff by laws (revision date April 12, 2017) provided by Staff Member # 2 on May 20, 2019 at 11:00 a.m. revealed the following. "Medical Record Content - The medical record must be sufficiently detailed to enable the practitioners responsible for the patient to provide continuing care of the patient to determine later what the patient's condition was at a specific time.
Diagnostic and Therapeutic Reports - The medical record must contain reports pertinent to care of the patient including: pathology and clinical laboratory reports; imaging studies; other diagnostic results; surgery/invasive procedures; and results of medical assessments and treatments."

A review of the facility's "DKA protocol - adult" provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m. reads in part "Initiate in Emergency Department. Diagnosis include: Blood Glucose greater than 250 mg/dl; Arterial pH less than 7.25; Plasma Bicarb less than/equal to 15; Anion Gap greater that 15; and + Ketones in urine."
There was no documentation the DKA protocol was followed.

2. The medical record of Patient #5 was reviewed on 5/21/19 at various times during the day. Patient #5 was a 49 year old transferred from another hospital's emergency department and admitted to ICU at this facility on 3/28/19 with the diagnosis of diabetic ketoacidosis (DKA ).

Patient #5 was placed on DKA protocol on admission. According to the facility's "DKA protocol - adult" provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m., the DKA protocol consist of the following:
1. Basic Metabolic Panel (BMP) (which is a measurement of: glucose, BUN (Blood Urea Nitrogen), creatinine, sodium, potassium, chloride, CO 2 (carbon dioxide), calcium and eGFR (Glomerular filtration rate)) every 2 hours until CO2 is greater than or equal to 15 mmol/l (millimoles per litre) and Anion Gap (AG) is less than 12.
2. Then BMP BID (twice daily) for 2 days.
3. PO 4 (Phosphate) every 12 hours times 2 then daily for 2 days.
4. MG (magnesium) every 12 hours times 2 then daily for 2 days.
5. If the pH on initial ABGs (Arterial Blood Gases) is less than 7.25 then repeat ABGs in 2 hours.

The medical record did not contain the DKA Flowsheets.

The physician's note dated 3/28/19 at 9:44 A.M. states, "...At presentation at the emergency room she was noted to be in DKA..." There was no documentation as to what the AG was at this time.
Nursing Note dated 3/28/19 at 5:33 P.M. states, "...Gap closed on second BMP..." There was no documentation as to what the AG was.
Nursing Note dated 3/29/19 at 3:07 P.M. states, "(Name of Physician) notified that pt (Patient #5) with closed gap (AG) since 6:00 this morning..." There was no documentation as to what the AG was at that time.
Nursing Note dated 3/29/19 at 9:14 P.M. states, "GAP reopened last night after transitioning to insulin pump." There was no documentation as to what the GAP was.

Staff Member #6 (Registered Nurse, Manager ICU) was interviewed on 5/21/19 at approximately 1:00 P.M. Staff Member #6 stated, "Once the patient has had two (2) consecutive AGs of 12 or below we will begin to transition them from ICU to the floor or sometimes we have discharged from ICU. The AGs are calculate every four (4) hours and documented on the DKA Flowsheet which is scanned into the medical record upon discharge."

Staff Member #3 was interviewed on 5/21/19 at approximately 1:35 P.M. and stated, "HIM (Health Information Management) and ICU could not locate the DKA Flowsheets."

Based on document review and interview, it was determined that the facility staff failed to maintain the clinical record consistent with the hospital policy and procedures to include all evaluations of the patient and appropriate findings for two (2) of seven (7) patients (Patients # 1 and # 5)

The findings include:

1. The medical record of Patient # 1 was reviewed on May 20 and May 21, 2019. Patient # 1 was a 23 year old who presented to the Emergency Department (ED) with complaint of hyperglycemia (500 at home about an hour prior to admission, took 9 units of humalog, finger stick blood glucose (FSBG) in triage was 362) and nausea on March 24, 2019 at 4:34 a.m.
At 4:40 a.m. Patient # 1 was placed in a room in the ED.
At 4:52 a.m. Documentation by the RN (Registered Nurse) reads "Patient reports feeling nausea and dehydrated at home. Checked BS @ home was 500 took 9 units @ home, called nurse hotline who advised to come in to ED. Hx of type 1 diabetes."
At 4:58 a.m. Orders were placed for CMP (comprehensive metabolic panel), CBC (complete blood count) with auto differential, sodium chloride 0.9% bolus 1,000 ml, and ondansetron injection 4 mg.
At 6:05 a.m. CMP results show Glucose 458.
6:15 a.m. Orders were placed for ondansetron injection 4 mg and sodium chloride 0.9% bolus 1,000 ml.
6:35 a.m. Discharge disposition selected by MD - ED Disposition set to discharge.
6:36 a.m. MD note reads in part "Patient is known insulin-dependent diabetic. [He/she] has an insulin pump. [He/she] checked blood sugar and it was over 500. [He/she] did urinate was positive for ketones. [He/she] gave [himself/herself] an additional 9 units to [his/her] insulin pump. [he/she] thinks [he/she] may have not given enough extra insulin after evening meal. [He/she] currently has no pain. [He/she] still feels somewhat nauseated."
"Diagnosis management comments" reads in part "Very nice patient. No evidence of DKA (diabetic ketoacidosis). [He/she] is very comfortable performing a sliding scale using [his/her] pump. [He/she] will monitor blood sugar closely. [He/she] has a very informed patient [he/she] returns any issues or new problems."
"Disposition" reads "Discharge."
"Diagnoses" reads "Non-intractable vomiting with nausea, unspecified vomiting type, hyperglycemia."
7:33 a.m. POC (point of care) glucose 360.
8:02 a.m. Patient discharged.

An interview with Staff Member # 4 on May 20, 2019 at 1:42 p.m. revealed the following. "There was a letter received by the facility on April 10, 2019 from [Patient # 1's family]. The ED Medical Director and the ED Nurse Manager reviewed the chart [ED Medical Director's name] stated "Did briefly have DKA during stay at [facility name] but it resolved before discharge and did not have an emergent medical condition." The ED manager agreed the "nursing care was appropriate for the patient." Facility staff spoke with [Patient # 1's family] on April 11, 2019 and also sent a letter informing [him/her] of the findings."

An interview with Staff Member # 7, Endocrinologist, on May 20, 2019 at 2:30 p.m. revealed "DKA doesn't always mean a high blood glucose. If the blood glucose is high then a urine should be checked for ketones and blood work is needed to determine DKA. Blood work would include at a minimum BMP (glucose, BUN (blood urea nitrogen), creatinine, sodium, potassium, chloride, CO2 (carbon dioxide), calcium, total protein, albumin, AST (aspartate aminotransferase), alkaline phosphatase, ALT (alanine aminotransferase), total bilirubin and eGFR (estimated glomerular filtration rate), pH (potential of hydrogen), bicarb (bicarbonate), anion gap and urine for ketones. A safe discharge glucose would be at least below 300, ideally below 250 in conjunction with other normal labs."
There is no documentation in the medical record for Patient # 1 to include a pH, bicarb, anion gap and urine for ketones.

An interview with Staff Member # 9, ED Medical Director on May 21, 2019 at 9:30 a.m. revealed "[Staff Member # 10' name] identified the high blood glucose, ordered IV fluids and a metabolic panel, calculated the anion gap and determined the patient was not in DKA. The anion gap is a manual calculation (Na - chloride - CO2). Anion gap of less than 15 is ok. The physician does not always document the anion gap. Three things are required to diagnosis DKA increased blood glucose, positive ketones and pH below 7.25."
When asked if after the review of this chart did [he/she] state "the patient did briefly have DKA during stay but it resolved before discharge and did not have emergent medical condition." Staff Member # 9 stated "That was a communication error during a phone conversation."
There was no documentation in the medical record for Patient # 1 to include a pH or urine for ketones.

A review of the Medical Staff by laws (revision date April 12, 2017) provided by Staff Member # 2 on May 20, 2019 at 11:00 a.m. revealed the following. "Medical Record Content - The medical record must be sufficiently detailed to enable the practitioners responsible for the patient to provide continuing care of the patient to determine later what the patient's condition was at a specific time.
Diagnostic and Therapeutic Reports - The medical record must contain reports pertinent to care of the patient including: pathology and clinical laboratory reports; imaging studies; other diagnostic results; surgery/invasive procedures; and results of medical assessments and treatments."

A review of the facility's "DKA protocol - adult" provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m. reads in part "Initiate in Emergency Department. Diagnosis include: Blood Glucose greater than 250 mg/dl; Arterial pH less than 7.25; Plasma Bicarb less than/equal to 15; Anion Gap greater that 15; and + Ketones in urine."
There was no documentation the DKA protocol was followed.

2. The medical record of Patient #5 was reviewed on 5/21/19 at various times during the day. Patient #5 was a 49 year old transferred from another hospital's emergency department and admitted to ICU at this facility on 3/28/19 with the diagnosis of diabetic ketoacidosis (DKA ).

Patient #5 was placed on DKA protocol on admission. According to the facility's "DKA protocol - adult" provided by Staff Member # 3 on May 20, 2019 at 2:15 p.m., the DKA protocol consists of the following:
1. Basic Metabolic Panel (BMP) (which is a measurement of: glucose, BUN (Blood Urea Nitrogen), creatinine, sodium, potassium, chloride, CO 2 (carbon dioxide), calcium and eGFR (Glomerular filtration rate)) every 2 hours until CO 2 is greater than or equal to 15 mmol/l (millimoles per litre) and Anion Gap (AG) is less than 12.
2. Then BMP BID (twice daily) for 2 days.
3. PO 4 (Phosphate) every 12 hours times 2 then daily for 2 days.
4. MG (magnesium) every 12 hours times 2 then daily for 2 days.
5. If the pH on initial ABGs (Arterial Blood Gases) is less than 7.25 then repeat ABGs in 2 hours.

The medical record did not contain the DKA Flowsheets.

The physician's note dated 3/28/19 at 9:44 A.M. states, "...At presentation at the emergency room she was noted to be in DKA..." There was no documentation as to what the AG was at this time.
Nursing Note dated 3/28/19 at 5:33 P.M. states, "...Gap closed on second BMP..." There was no documentation as to what the AG was.
Nursing Note dated 3/29/19 at 3:07 P.M. states, "(Name of Physician) notified that pt (Patient #5) with closed gap (AG) since 6:00 this morning..." There was no documentation as to what the AG was at that time.
Nursing Note dated 3/29/19 at 9:14 P.M. states, "GAP reopened last night after transitioning to insulin pump." There was no documentation as to what the GAP was.

Staff Member #6 (Registered Nurse, Manager ICU) was interviewed on 5/21/19 at approximately 1:00 P.M. Staff Member #6 stated, "Once the patient has had two (2) consecutive AGs of 12 or below we will begin to transition them from ICU to the floor or sometimes we have discharged from ICU. The AGs are calculate every four (4) hours and documented on the DKA Flowsheet which is scanned into the medical record upon discharge."

Staff Member #3 was interviewed on 5/21/19 at approximately 1:35 P.M. and stated, "HIM (Health Information Management) and ICU could not locate the DKA Flowsheets."