HospitalInspections.org

Based on document review and interview it was determined for 1 of 5 (Pt #1) patient's medical records reviewed of patients admitted to the Behavioral Health Unit (BHU), the Hospital failed to ensure the patient's blood glucose levels were being properly managed by ongoing assessments and interventions, potentially affecting all diabetic patients receiving care in a 100 bed BHU. (Current census of 25)

Findings include:

1. On 04/19/2021 at 2:00 PM, the medical record of Pt #1 was reviewed. Pt #1 was admitted to the Behavioral Health Unit (BHU) on 03/20/2021 with the diagnoses of major depressive disorder and type 1 diabetes. Prior to admission the patient was using an insulin pump to control the patients' diabetes. The insulin pump was removed for the patient's safety due to suicidal ideation. The patient was started on Humalog insulin. Nurse Practitioner (E #2) medically screened Pt #1and dictated medical orders at 10:30 AM, which included orders for blood sugar checks at AC (before all meals), HS (hour of sleep). A 03/20/2021 "Communication To Nursing Note" by E #2 included the following: "patient is to have Pt's glucose taken if voices abnormal change or symptom, or is requesting additional check outside of current order of AC, HS and 0200. Patient is normally treated with an insulin pump and may require more frequent accu checks." E #2 failed to put an order in for the 2:00 AM accu check, which would have included insulin dosing for blood glucose level above 150. The "Sliding Scale" for blood glucose for AC and HS was ordered as follows:

For blood glucose below 70, give 0 units insulin
From 70 to 150 give 0 units of insulin
From 151 to 200 give 3 units of insulin
From 201 to 250 give 6 units of insulin
From 251 to 300 give 8 units of insulin
From 301 to 350 give 10 units of insulin
From 351 to 400 give 12 units of insulin
For blood glucose above 400, give 14 units of insulin, notify physician and recheck glucose in 1 hour for lispro or 2 hours for regular.

The following blood sugar readings and interventions were as follows:


DATE@TIME=READING=INTERVENTION

03/22/2021 @ 08:54=390=insulin given 03/21/2021 @ 02:01=291=no insulin given
03/22/2021 @ 07:23=408=insulin given 03/20/2021 @ 20:54=211=insulin given
03/22/2021 @ 02:06=173=no insulin given 03/20/2021 @ 16:59=194=insulin given
03/21/2021 @ 20:26=202=insulin given 03/20/2021 @ 10:45=334=insulin given
03/21/2021 @ 16:36=187=insulin given 03/20/2021 @ 07:37=259=insulin given
03/21/2021 @ 11:47=165=insulin given 03/20/2021 @ 06:28=208=insulin given
03/21/2021 @ 07:30=358=insulin given

2. There was no evidence that the Pt #1 was given any insulin, (per the 03/20/2021, Nurse Communication Note by E #2) on 03/21/2021, when the patient's blood glucose level was 291 at 2:01 AM. The patient should have received 8 units of insulin. There was no evidence that Pt #1 was given any insulin on 03/22/2021, when Pt #1's blood glucose level was 173. Pt #1 should have received 3 units of insulin. There was no evidence the physician was notified, as ordered, when the patient's blood glucose was above 400 on 03/22/2021 at 7:23 AM, or that the patient's glucose was rechecked an hour later.

3. On 04/20/2021 at 10:00 AM, an interview with the Quality Coordinator (E #7) was conducted. E #7 reviewed the electronic medical record of Pt #1 and confirmed that the glucose levels of Pt #1 were not properly managed. E #7 indicated the nurses on the Behavioral Care Unit should have clarified the communication note written by the Nurse Practitioner (E #2) and given insulin per the communication note.