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Based on medical record review and staff interviews a registered nurse did not supervise and evaluate the nursing care for Patient #1, specifically not executing a physician order and not completing patient discharge instructions.

Findings:

Review of Physician Order Sheet dated 05/04/12 at 1330 revealed Lantus 28 units at 0700 if patient eats, and at 1900; Glucometer testing before meals and at bedtime, and low dose sliding scale with Humalog.

Review of Discharge Medication Administration Record, Scheduled Medications revealed Humalog Before meals and at Bedtime 70 to 130 give 0 units, 131 to 180 give 2 units, 181 to 240 give 4 units, 241 to 300 give 6 units, 301 to 350 give 8 units, 351 to 400 give 10 units, 401 to 999 give 12 units, notify physician if blood sugar greater than 400.
On 05/06/12 at 2100 Patient #1 had a blood sugar of 170. Humalog insulin is charted as not administered with a charted reason as glucose within normal limits.

Review of Physician Order Sheet dated 05/05/12 revealed Cipro 250mg po bid x7 days.

Review of Physician Order dated 05/08/12 revealed an order written and signed by Staff #2 that the patient is medically stable to be discharged.

Review of Nursing Progress Note dated 05/08/12 revealed that the patient's daughter called and stated that she was going to pick the patient up. Charge Nurse, Nursing Supervisor, and Staff #1 notified. Staff #1 gave the discharge orders.

The patient's family showed up and was informed that since this was an informal discharge, there were no scripts or follow-up appointments. It was explained that Social Work hadn't had a chance to make follow-up appointments. Patient took evening medications, which included Cipro, Pepcid, and Seroquel. Patient was escorted downstairs via wheelchair and discharged to family care at approximately 1830.

Review of Behavioral Health Comprehensive Interdisciplinary Treatment Plan Discharge Planning Form dated 05/09/12 revealed no evidence of patient discharge instructions regarding medications including Cipro(day #4), follow-up appointment with the physician, and signs/symptoms for when to call the physician.