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Based on review of the medical record and staff interview, it was determined that the nurse executive failed to require 1 of 1 patient's blood glucose testing was conducted by the nursing staff according to physician's orders (Patient #1). This deficient practice posed the potential that immediate feedback would be compromised on how the patient's blood glucose was effectively managed.

Findings include:

Patient #1 was admitted on 06/14/17 for long term treatment of hypertension, cardiomyopathy, shortness of breath, congestive heart failure, diabetes mellitus type II, atrial fibrillation, chronic kidney disease, non-compliance, and dietary indiscretion. The patient was discharged to an acute short term care hospital on 08/21/17 for cardiac surgery.

The physician ordered on 07/24/17: "accucheck daily at 1130", according to the medical record. The Glycemic Management Log confirmed that 19 of 19 blood sugars documented between 07/24/17 and 08/21/17 (inclusive) were not performed at 1130 per physician's order.

Charge Nurse RN #11 confirmed the documentation during an interview conducted on 08/22/17.

The staff did not conduct the patient's blood glucose daily at 1130, according to physician's orders.