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Based on review of documentation, interviews, review of the Root Cause Analyses, and the plan of correction, the Hospital failed to identify opportunities for improvement and changes that will lead to improvement.

Findings included:

1) The Department of Nursing did not identify additional opportunities for improvement of care for managing patients with hyperglycemia. The Plan of correction did not identify actions taken to provide counseling and remediation for Nurse #1 and #2. Review of the Hospital policy titled: Blood Glucose Point of Care Testing indicated that, Point 2. Blood glucose is tested according to physician order or at the nurse's discretion. Both Nurse #1 and #2 recorded abnormal blood sugar values with no follow up testing, no notification of the Patient's physician and no development of an individualized nursing care plan for Patient #1.

2) Revisions made to the policies titled Blood Glucose Point of Testing and Insulin Administration and the Management of Blood Glucose Levels indicated that minimal changes were made to the policies to clearly indicate frequency of finger stick blood sugar testing. For example, "bedtime" was still not clarified to specify the time. Lack of clarity regarding bedtime results in the lack of specificity of when to obtain follow-up tests at 4 and 6 hours.

3) There was no policy developed to address patients with Hyperglycemia and still no clinical guideline developed as to when to notify the physician of abnormal values for high glucose values.

4) The plan to provide education to nursing staff regarding the management of patients with hyperglycemia included only three questions added to the Insulin Competency Packets and competency test. Two of the three test questions pertained to testing and resultant testing of finger stick blood sugars after "bedtime" which was not clarified.

Based on review of the medical record and interviews, the hospital failed to ensure that the registered nurse supervised and evaluated the nursing care for the management of Patient #1's blood glucose values.

Findings included:

The Facility reported that on 3/18/11 at 7:45 am, a Patient went into cardiopulmonary arrest in the Pre-Anesthesia Care Unit [PACU]. Resuscitation efforts were not successful and the Patient was pronounced at 8:44 am.


Background information:

Review of Emergency Department [ED] documentation dated 3/17/11 at 1:38 pm indicated Patient #1 presented after falling and injuring his/her left leg. Patient #1 had diagnoses of Type I Diabetes managed with sliding scale insulin; hepatitis C [infection of the liver]; diabetic neuropathy [degeneration of peripheral nerves which results in poor circulation, loss of sensation and pain in the extremities].

Emergency Medical Services [EMS] responders arrived on 3/17/11 at 12:52 pm. Patient #1 was assessed and a finger stick blood sugar [fsbs] was obtained and noted to be critically low at 33. Glucagon (oral administration of glucose/sugar) was administered by the EMS team with the blood sugar increasing to 54 at 1:05 pm.

ED documentation on 3/17/11 indicated that an intravenous line was established to infuse glucose and Patient #1 also received orange juice to drink. A repeat FSBS obtained in the ED at 2:40 pm was reported as 232 [normal values are 70-110 mg/dl]. A laboratory draw of venous blood obtained at 3 pm indicated the blood sugar was 311. Vital signs were recorded at 5:53 pm as blood pressure 110/67 [normal is 120/80] pulse 102 [normal is 80 beats per minute] with normal respiratory rate and oxygen saturation. Patient #1's blood sugar at 5:30 pm was 311.

An x-ray obtained in the ED indicated Patient #1 was diagnosed with a left displaced tibia/fibula fracture [broken bones in the calf area]. The Patient was admitted to the Medical/Surgical inpatient unit under the Hospitalist service at 6:00 pm.. Surgery to repair the fracture was planned for 3/18/11 as an add on surgical case.

Findings included:

1) During the evening of 3/17/11, Nurse #1 recorded Patient #1's finger stick blood sugar values as:

6:30 pm - 389 mg/dl
10 units of insulin was administered per sliding scale orders for meal time administration.
7:06 pm - 389 mg/dl
8:48 pm - 309 mg/dl

No additional blood sugars were obtained throughout the evening shift, despite the fact that several abnormal values were recorded.

Review of Nurse #1 documentation indicated that the Hospitalist Attending Physician was not notified of the abnormal/high blood sugar values.

Review of the Physician's order for fsbs testing dated 3/17/11 at 5:37 pm indicated that a fsbs must be obtained: 1) before meals (within 30 minutes) and at bedtime. Review of hospital policy indicated that no specific time was recorded for "bedtime." Interview with the VP of Patient Care Services indicated that bedtime could be anywhere from 9 - 11 pm. 2) two hours after giving any bedtime Humalog or Regular and 3) Every 6 hours if NPO [nothing by mouth]. Patient #1 was also ordered to be NPO after midnight for impending surgery the following day.

Review of the Human Insulin orders dated 3/17/11 at 5:48 pm indicated the orders pertained to AC [before meals] and were PRN reason for hyperglycemia. The Hospitalist who wrote the orders, was interviewed on 4/5/11 at 10 am. The Hospitalist clarified the orders to administer insulin only pertained to mealtimes. Based on a sliding scale based on the blood sugar value, a certain amount of insulin was to be administered.

2) At 7:06 pm, Patient #1's pulse was 115 and the blood pressure was 137/69. At 11 pm, Patient #1's pulse was 123 and the blood pressure was 108/54. Review of Nurse #1 documentation indicated that the Hospitalist Attending Physician was not notified of the change in vital signs: increase in heart rate and drop in blood pressure.

Review of the Hospital Protocols indicated that vital signs were to be obtained once a shift. No direction was provided regarding notifying the Physician of abnormal vital signs or when additional vital signs should be obtained if vitals signs were not within normal limits. However, general nursing practice/ standards require that the patient's attending physician should be notified of abnormal clinical findings and further directions be obtained.


Nurse #1 was interviewed on 4/4/11 at 1:40 pm. Nurse #1 said 10 unit of sliding scale insulin was administered at mealtime, per orders, for the fsbs of 389. Nurse #1 said she rechecked the fsbs at 7:06 pm and it was still 389. Nurse #1 said the last check was done at 8:48 pm during her shift and it was 309. Nurse #1 said nothing was ordered to cover Patient #1's blood sugar of 309 "because patients bottom out during the night." Nurse #1 said a nurse can re-check blood sugars on patients based on their judgment. Nurse #1 said Patient #1 ate very little [food at] dinner - only a couple bites- that's it. Nurse #1 said the fsbs was down 80 points two hours later. Nurse #1 said Patient #1 demonstrated no signs of hypoglycemia. Nurse #1 said she was concerned the patient had not taken in enough food before being placed on NPO [nothing by mouth - no food or fluids] after midnight in preparation for surgery. Nurse #1 said Patient #1 was an add on for the surgery and not scheduled - the operating room would call when they could fit the surgery in the days schedule. Nurse #1 said she offered Patient #1 a menu at 11:15 pm and she/he was alert and oriented, but threw the menu and said she/he was not gonna eat diabetic S***. Nurse #1 said she was concerned because Patient #1 was receiving normal saline [provides fluids and contains no glucose] per intravenous infusion, ate very little dinner and received 10 units of insulin. Nurse #1 said a re-check of the fsbs would be due at midnight.

3) Review of the night shift nursing/Nurse #2 documentation indicated that no blood sugars were checked the entire night shift.

No vital signs were obtained until 7:15 am with the pulse recorded as 130 and the blood pressure 87/55.

Review of Nurse #1 documentation indicated Hospitalist Attending Physician was not notified of the change in vital signs: continued downward trend in blood pressure and rise in heart rate.

A period of 10 hours elapsed where Patient #1's blood sugar was not checked.

No additional vital signs were obtained.

The Patient was evaluated by the Admitting Physician/Hospitalist at 6:50 pm, shortly after admission. There were no additional assessments of Patient #1 conducted by the Hospitalist Services.

Review of Nurse #2's documentation indicated the Orthopedic Surgeon was in at 6 am to evaluate the Patient for surgery. Surgery to repair the fracture was planned for 8 am.

4) The fasting blood sugar obtained by finger stick was obtained at 7:00 am registered as "critically high" according to the glucose testing machine on the unit. According to hospital policy, all critical values must be followed by a laboratory venous draw because very low and very high values [the machine registers high values to only 450] sensed by the machine must be confirmed by a Laboratory venous draw and analyzed by machinery in the main lab. Laboratory report documentation at 7:15 am indicated the confirmed critical high value of 878 was called to the PACU registered nurse. Hospital policy also required that the Licensed Independent Practitioners be notified. However, the Hospitalist/Attending was never notified of the critically high report from the machine on the Medical/Surgical Unit.

On 3/18/11 at 7:15 am, Patient #1's pulse was 130 and the blood pressure was 87/55. Documentation at 7:18 am indicated that Nurse #2 transported Patient #2 "to the PACU in stable condition."

On arrival to the PACU, during Nurse #2's report to the PACU Nurse, Patient #1 was observed to be moaning, restless, agitated, confused and trying to get out of bed. Vital signs obtained in the PACU were blood pressure 71/39 and heart rate of 110. Patient #1 was placed on a monitor and an abnormal heart rhythm was noted. An ECG was obtained that demonstrated sinus tachycardia with a right Bundle Branch Block[defect in the hearts electrical conduction system]. At 8 am, Patient #1 went into cardiac arrest and immediate resuscitation was provided. Resuscitation ended at 8:44 am.

5) Nurse #2 was interviewed in person on 4/4/11 at 11:40 am. Nurse #2 said she assumed care of Patient #1 at 11 pm and she/he had just gotten comfortable and was asleep. Nurse #2 said she wanted to wait to conduct a full assessment of the patient until she/he woke and asked for pain medication. Nurse #2 said the patient slept from 11 pm to 5 am and the Certified Nurse Aide [CNA] did hourly checks on Patient #1 and reported the patient was asleep the entire time. Nurse #2 said she was busy with a critically ill patient assigned to her from 11 to 4 am, when the patient went to the operating room.

Nurse #2 said she conducted a full assessment of Patient #1 at 5 am when she/he woke and asked for a pain medication. Nurse #2 said Patient #1 was alert and oriented times three and had a pain level of 10 out of 10, so medication was administered. Nurse #2 said they discussed the impending surgery.

Review of the Hospital Policy titled: Documentation of Nursing Care, section on Shift Assessment, indicated that the shift assessment is completed by the nurse caring for the patient at the beginning of the shift. The purpose of the shift assessment is to document and plan the care of the Patient.

6) Nurse #2 said the last fsbs obtained around 9 pm was 309, which was high or hyperglycemia. Nurse #2 said she was not worried about hyperglycemia because Patient came in for hypoglycemia [low blood sugar]. Nurse #2 said she did not re-check a fsbs because the evening shift nurse/Nurse #1 did not give [an extra dose of late in the evening] insulin. Nurse #2 said she did not ask the CNA to check a fsbs [a registered nurse must direct the CNA to obtain a fsbs, the CNA cannot independently obtain one] because she was not concerned about Patient #1 - the CNA was checking on him/her hourly and it "never crossed my mind" to ask the CNA to get one (a fsbs). Nurse #2 said she did not assume the patient's blood sugar would go up because the patient was receiving normal saline [does not contain glucose] and was NPO after midnight. Nurse #2 said they usually don't get a fsbs at midnight if it's not ordered. When this Surveyor pointed out that reportedly, hospital protocol was to obtain one at midnight ,if the patient was NPO, Nurse #2 said it slipped her mind, she was busy with the other critically ill patient assigned to her.

7) The CNA was interviewed on 4/5/11 at 8 am. The CNA said Nurse #2 did not direct her to obtain a fsbs. The CNA said she cannot obtain a fsbs without a nurses direction to do so. The CNA said she conducted the hourly checks on Patient #1 and the RN documents the checks. Review of documentation indicated the CNA did perform hourly checks on Patient #1.

8) Review of the Hospital policy titled: Blood Glucose Point of Care Testing indicated that, Point 2) Blood glucose is tested according to physician's order or at the nurse's discretion and 3) Test results are definitive in that clinical treatment decisions of diagnoses may be based upon the results. Review of the section titled Patient Testing, point 4 indicated that whole blood glucose levels less than 50 mg/dl and greater than 450 mg/dl must be confirmed by venous specimen and tested in the laboratory. The policy contained no narrative regarding notifying the physician regarding the critical values.

9) Review of the Hospital Policy titled: Insulin Administration and the Management of Blood Glucose Levels, section on Policy, point 4 indicated that: When short acting insulin is used to correct hyperglycemia at bedtime, a blood glucose, fsbs, will be checked at two (2) hours and 4-6 hours following administration of the supplemental dose and/or if the patient exhibits symptoms of hypoglycemic reaction: pallor, diaphoresis, tachycardia, agitation, irrational/uncontrolled behavior, shakiness, confusion, slurred speech, somnolence and extreme fatigue.

10) Interview with the Risk Manager and the VP for Patient Care Services indicated there was no specific policy related to the clinical management of patients with hyperglycemia.

11) The Hospitalist Attending Physician was interviewed in person on 4/5/11 at 10 am. The Hospitalist said he first saw Patient #1 around 5 pm in the ED for evaluation for admission. The Hospitalist said Patient #1 had a high blood sugar, but he expected this because stress and pain can raise the glucose level in a frail diabetic, such as this patient was, and the patient received several doses of glucose intravenously in the ED to raise the blood sugar from critical lows of 33 and 52 obtained in the field by EMS staff.

The Hospitalist clarified the orders in regards to the term, "bedtime" which he considers to be 9 pm. The Hospitalist further clarified that blood sugars should be checked two times after the last dose of insulin administration: check one is two hours after insulin administration and then check two is 6 hours after that time. The Hospitalist further clarified that fsbs must be checked at midnight by protocol because the morning dose is administered at 6:30 am. The Hospitalist said that once a patient is made NPO, a fsbs must be obtained every six hours, so one should be obtained at midnight and the other six hours later at 6 am.

Please refer to the admission orders, this assumption, as explained by the Physician is not clear in the written orders.

The Hospitalist said he never received a call from Nurse #1 regarding reporting abnormal blood sugar values or to receive direction for the "bedtime" or "HS/hour of sleep" dose to be administered at 9 pm based on the high fsbs documented as 309. The Hospitalist said that typically, the nurse will call for orders since none were written and the patient was going to be made NPO. The Hospitalist said he would have not ordered insulin because of the risk of inducing another drop in blood sugar/hypoglycemia, but would have ordered more frequent fsbs testing and treated based on the results. The Hospitalist said Nurse #1 should have called for direction.

The Hospitalist said Nurse #2 should have obtained the fasting blood sugar level at 6 am based on NPO status at midnight - and- most critically - because Patient #1 was pending surgery. The Hospitalist said the fasting blood sugar obtained with the unit machine was done late: at 7:15 and it was reported as critically high - which must be called to the Covering Physician first and then the laboratory draw also obtained.

The Hospitalist said this was a multi-step process for each abnormal finding: the vital signs trending and the blood sugars remaining high with no additional checks - should have been reported to the physician. The Hospitalist said he would have directed care based on his clinical opinion of what to do. The Hospitalist said that the nurses should have called for direction for any abnormal values. The Hospitalist said Patient #1 was not stable while being transported to the PACU for surgery with a high heart rate, low blood pressure and critical value blood sugar and not acting normally.

Based on review of documentation,the root causes analyses and plan of correction and interviews, the Hospital failed to ensure that the nursing staff developed and kept current, a nursing care plan for the management of Patient #1's abnormal blood sugar.

Findings included:

1) Please refer to Tag A 3952 for specific information.

Based on review of documentation, interviews, review of the Root Cause Analyses, and the plan of correction, the Hospital failed to identify opportunities for improvement and changes that will lead to improvement.

Findings included:

1) The Department of Nursing did not identify additional opportunities for improvement of care for managing patients with hyperglycemia. The Plan of correction did not identify actions taken to provide counseling and remediation for Nurse #1 and #2. Review of the Hospital policy titled: Blood Glucose Point of Care Testing indicated that, Point 2. Blood glucose is tested according to physician order or at the nurse's discretion. Both Nurse #1 and #2 recorded abnormal blood sugar values with no follow up testing, no notification of the Patient's physician and no development of an individualized nursing care plan for Patient #1.

2) Revisions made to the policies titled Blood Glucose Point of Testing and Insulin Administration and the Management of Blood Glucose Levels indicated that minimal changes were made to the policies to clearly indicate frequency of finger stick blood sugar testing. For example, "bedtime" was still not clarified to specify the time. Lack of clarity regarding bedtime results in the lack of specificity of when to obtain follow-up tests at 4 and 6 hours.

3) There was no policy developed to address patients with Hyperglycemia and still no clinical guideline developed as to when to notify the physician of abnormal values for high glucose values.

4) The plan to provide education to nursing staff regarding the management of patients with hyperglycemia included only three questions added to the Insulin Competency Packets and competency test. Two of the three test questions pertained to testing and resultant testing of finger stick blood sugars after "bedtime" which was not clarified.

Based on review of the medical record and interviews, the hospital failed to ensure that the registered nurse supervised and evaluated the nursing care for the management of Patient #1's blood glucose values.

Findings included:

The Facility reported that on 3/18/11 at 7:45 am, a Patient went into cardiopulmonary arrest in the Pre-Anesthesia Care Unit [PACU]. Resuscitation efforts were not successful and the Patient was pronounced at 8:44 am.


Background information:

Review of Emergency Department [ED] documentation dated 3/17/11 at 1:38 pm indicated Patient #1 presented after falling and injuring his/her left leg. Patient #1 had diagnoses of Type I Diabetes managed with sliding scale insulin; hepatitis C [infection of the liver]; diabetic neuropathy [degeneration of peripheral nerves which results in poor circulation, loss of sensation and pain in the extremities].

Emergency Medical Services [EMS] responders arrived on 3/17/11 at 12:52 pm. Patient #1 was assessed and a finger stick blood sugar [fsbs] was obtained and noted to be critically low at 33. Glucagon (oral administration of glucose/sugar) was administered by the EMS team with the blood sugar increasing to 54 at 1:05 pm.

ED documentation on 3/17/11 indicated that an intravenous line was established to infuse glucose and Patient #1 also received orange juice to drink. A repeat FSBS obtained in the ED at 2:40 pm was reported as 232 [normal values are 70-110 mg/dl]. A laboratory draw of venous blood obtained at 3 pm indicated the blood sugar was 311. Vital signs were recorded at 5:53 pm as blood pressure 110/67 [normal is 120/80] pulse 102 [normal is 80 beats per minute] with normal respiratory rate and oxygen saturation. Patient #1's blood sugar at 5:30 pm was 311.

An x-ray obtained in the ED indicated Patient #1 was diagnosed with a left displaced tibia/fibula fracture [broken bones in the calf area]. The Patient was admitted to the Medical/Surgical inpatient unit under the Hospitalist service at 6:00 pm.. Surgery to repair the fracture was planned for 3/18/11 as an add on surgical case.

Findings included:

1) During the evening of 3/17/11, Nurse #1 recorded Patient #1's finger stick blood sugar values as:

6:30 pm - 389 mg/dl
10 units of insulin was administered per sliding scale orders for meal time administration.
7:06 pm - 389 mg/dl
8:48 pm - 309 mg/dl

No additional blood sugars were obtained throughout the evening shift, despite the fact that several abnormal values were recorded.

Review of Nurse #1 documentation indicated that the Hospitalist Attending Physician was not notified of the abnormal/high blood sugar values.

Review of the Physician's order for fsbs testing dated 3/17/11 at 5:37 pm indicated that a fsbs must be obtained: 1) before meals (within 30 minutes) and at bedtime. Review of hospital policy indicated that no specific time was recorded for "bedtime." Interview with the VP of Patient Care Services indicated that bedtime could be anywhere from 9 - 11 pm. 2) two hours after giving any bedtime Humalog or Regular and 3) Every 6 hours if NPO [nothing by mouth]. Patient #1 was also ordered to be NPO after midnight for impending surgery the following day.

Review of the Human Insulin orders dated 3/17/11 at 5:48 pm indicated the orders pertained to AC [before meals] and were PRN reason for hyperglycemia. The Hospitalist who wrote the orders, was interviewed on 4/5/11 at 10 am. The Hospitalist clarified the orders to administer insulin only pertained to mealtimes. Based on a sliding scale based on the blood sugar value, a certain amount of insulin was to be administered.

2) At 7:06 pm, Patient #1's pulse was 115 and the blood pressure was 137/69. At 11 pm, Patient #1's pulse was 123 and the blood pressure was 108/54. Review of Nurse #1 documentation indicated that the Hospitalist Attending Physician was not notified of the change in vital signs: increase in heart rate and drop in blood pressure.

Review of the Hospital Protocols indicated that vital signs were to be obtained once a shift. No direction was provided regarding notifying the Physician of abnormal vital signs or when additional vital signs should be obtained if vitals signs were not within normal limits. However, general nursing practice/ standards require that the patient's attending physician should be notified of abnormal clinical findings and further directions be obtained.


Nurse #1 was interviewed on 4/4/11 at 1:40 pm. Nurse #1 said 10 unit of sliding scale insulin was administered at mealtime, per orders, for the fsbs of 389. Nurse #1 said she rechecked the fsbs at 7:06 pm and it was still 389. Nurse #1 said the last check was done at 8:48 pm during her shift and it was 309. Nurse #1 said nothing was ordered to cover Patient #1's blood sugar of 309 "because patients bottom out during the night." Nurse #1 said a nurse can re-check blood sugars on patients based on their judgment. Nurse #1 said Patient #1 ate very little [food at] dinner - only a couple bites- that's it. Nurse #1 said the fsbs was down 80 points two hours later. Nurse #1 said Patient #1 demonstrated no signs of hypoglycemia. Nurse #1 said she was concerned the patient had not taken in enough food before being placed on NPO [nothing by mouth - no food or fluids] after midnight in preparation for surgery. Nurse #1 said Patient #1 was an add on for the surgery and not scheduled - the operating room would call when they could fit the surgery in the days schedule. Nurse #1 said she offered Patient #1 a menu at 11:15 pm and she/he was alert and oriented, but threw the menu and said she/he was not gonna eat diabetic S***. Nurse #1 said she was concerned because Patient #1 was receiving normal saline [provides fluids and contains no glucose] per intravenous infusion, ate very little dinner and received 10 units of insulin. Nurse #1 said a re-check of the fsbs would be due at midnight.

3) Review of the night shift nursing/Nurse #2 documentation indicated that no blood sugars were checked the entire night shift.

No vital signs were obtained until 7:15 am with the pulse recorded as 130 and the blood pressure 87/55.

Review of Nurse #1 documentation indicated Hospitalist Attending Physician was not notified of the change in vital signs: continued downward trend in blood pressure and rise in heart rate.

A period of 10 hours elapsed where Patient #1's blood sugar was not checked.

No additional vital signs were obtained.

The Patient was evaluated by the Admitting Physician/Hospitalist at 6:50 pm, shortly after admission. There were no additional assessments of Patient #1 conducted by the Hospitalist Services.

Review of Nurse #2's documentation indicated the Orthopedic Surgeon was in at 6 am to evaluate the Patient for surgery. Surgery to repair the fracture was planned for 8 am.

4) The fasting blood sugar obtained by finger stick was obtained at 7:00 am registered as "critically high" according to the glucose testing machine on the unit. According to hospital policy, all critical values must be followed by a laboratory venous draw because very low and very high values [the machine registers high values to only 450] sensed by the machine must be confirmed by a Laboratory venous draw and analyzed by machinery in the main lab. Laboratory report documentation at 7:15 am indicated the confirmed critical high value of 878 was called to the PACU registered nurse. Hospital policy also required that the Licensed Independent Practitioners be notified. However, the Hospitalist/Attending was never notified of the critically high report from the machine on the Medical/Surgical Unit.

On 3/18/11 at 7:15 am, Patient #1's pulse was 130 and the blood pressure was 87/55. Documentation at 7:18 am indicated that Nurse #2 transported Patient #2 "to the PACU in stable condition."

On arrival to the PACU, during Nurse #2's report to the PACU Nurse, Patient #1 was observed to be moaning, restless, agitated, confused and trying to get out of bed. Vital signs obtained in the PACU were blood pressure 71/39 and heart rate of 110. Patient #1 was placed on a monitor and an abnormal heart rhythm was noted. An ECG was obtained that demonstrated sinus tachycardia with a right Bundle Branch Block[defect in the hearts electrical conduction system]. At 8 am, Patient #1 went into cardiac arrest and immediate resuscitation was provided. Resuscitation ended at 8:44 am.

5) Nurse #2 was interviewed in person on 4/4/11 at 11:40 am. Nurse #2 said she assumed care of Patient #1 at 11 pm and she/he had just gotten comfortable and was asleep. Nurse #2 said she wanted to wait to conduct a full assessment of the patient until she/he woke and asked for pain medication. Nurse #2 said the patient slept from 11 pm to 5 am and the Certified Nurse Aide [CNA] did hourly checks on Patient #1 and reported the patient was asleep the entire time. Nurse #2 said she was busy with a critically ill patient assigned to her from 11 to 4 am, when the patient went to the operating room.

Nurse #2 said she conducted a full assessment of Patient #1 at 5 am when she/he woke and asked for a pain medication. Nurse #2 said Patient #1 was alert and oriented times three and had a pain level of 10 out of 10, so medication was administered. Nurse #2 said they discussed the impending surgery.

Review of the Hospital Policy titled: Documentation of Nursing Care, section on Shift Assessment, indicated that the shift assessment is completed by the nurse caring for the patient at the beginning of the shift. The purpose of the shift assessment is to document and plan the care of the Patient.

6) Nurse #2 said the last fsbs obtained around 9 pm was 309, which was high or hyperglycemia. Nurse #2 said she was not worried about hyperglycemia because Patient came in for hypoglycemia [low blood sugar]. Nurse #2 said she did not re-check a fsbs because the evening shift nurse/Nurse #1 did not give [an extra dose of late in the evening] insulin. Nurse #2 said she did not ask the CNA to check a fsbs [a registered nurse must direct the CNA to obtain a fsbs, the CNA cannot independently obtain one] because she was not concerned about Patient #1 - the CNA was checking on him/her hourly and it "never crossed my mind" to ask the CNA to get one (a fsbs). Nurse #2 said she did not assume the patient's blood sugar would go up because the patient was receiving normal saline [does not contain glucose] and was NPO after midnight. Nurse #2 said they usually don't get a fsbs at midnight if it's not ordered. When this Surveyor pointed out that reportedly, hospital protocol was to obtain one at midnight ,if the patient was NPO, Nurse #2 said it slipped her mind, she was busy with the other critically ill patient assigned to her.

7) The CNA was interviewed on 4/5/11 at 8 am. The CNA said Nurse #2 did not direct her to obtain a fsbs. The CNA said she cannot obtain a fsbs without a nurses direction to do so. The CNA said she conducted the hourly checks on Patient #1 and the RN documents the checks. Review of documentation indicated the CNA did perform hourly checks on Patient #1.

8) Review of the Hospital policy titled: Blood Glucose Point of Care Testing indicated that, Point 2) Blood glucose is tested according to physician's order or at the nurse's discretion and 3) Test results are definitive in that clinical treatment decisions of diagnoses may be based upon the results. Review of the section titled Patient Testing, point 4 indicated that whole blood glucose levels less than 50 mg/dl and greater than 450 mg/dl must be confirmed by venous specimen and tested in the laboratory. The policy contained no narrative regarding notifying the physician regarding the critical values.

9) Review of the Hospital Policy titled: Insulin Administration and the Management of Blood Glucose Levels, section on Policy, point 4 indicated that: When short acting insulin is used to correct hyperglycemia at bedtime, a blood glucose, fsbs, will be checked at two (2) hours and 4-6 hours following administration of the supplemental dose and/or if the patient exhibits symptoms of hypoglycemic reaction: pallor, diaphoresis, tachycardia, agitation, irrational/uncontrolled behavior, shakiness, confusion, slurred speech, somnolence and extreme fatigue.

10) Interview with the Risk Manager and the VP for Patient Care Services indicated there was no specific policy related to the clinical management of patients with hyperglycemia.

11) The Hospitalist Attending Physician was interviewed in person on 4/5/11 at 10 am. The Hospitalist said he first saw Patient #1 around 5 pm in the ED for evaluation for admission. The Hospitalist said Patient #1 had a high blood sugar, but he expected this because stress and pain can raise the glucose level in a frail diabetic, such as this patient was, and the patient received several doses of glucose intravenously in the ED to raise the blood sugar from critical lows of 33 and 52 obtained in the field by EMS staff.

The Hospitalist clarified the orders in regards to the term, "bedtime" which he considers to be 9 pm. The Hospitalist further clarified that blood sugars should be checked two times after the last dose of insulin administration: check one is two hours after insulin administration and then check two is 6 hours after that time. The Hospitalist further clarified that fsbs must be checked at midnight by protocol because the morning dose is administered at 6:30 am. The Hospitalist said that once a patient is made NPO, a fsbs must be obtained every six hours, so one should be obtained at midnight and the other six hours later at 6 am.

Please refer to the admission orders, this assumption, as explained by the Physician is not clear in the written orders.

The Hospitalist said he never received a call from Nurse #1 regarding reporting abnormal blood sugar values or to receive direction for the "bedtime" or "HS/hour of sleep" dose to be administered at 9 pm based on the high fsbs documented as 309. The Hospitalist said that typically, the nurse will call for orders since none were written and the patient was going to be made NPO. The Hospitalist said he would have not ordered insulin because of the risk of inducing another drop in blood sugar/hypoglycemia, but would have ordered more frequent fsbs testing and treated based on the results. The Hospitalist said Nurse #1 should have called for direction.

The Hospitalist said Nurse #2 should have obtained the fasting blood sugar level at 6 am based on NPO status at midnight - and- most critically - because Patient #1 was pending surgery. The Hospitalist said the fasting blood sugar obtained with the unit machine was done late: at 7:15 and it was reported as critically high - which must be called to the Covering Physician first and then the laboratory draw also obtained.

The Hospitalist said this was a multi-step process for each abnormal finding: the vital signs trending and the blood sugars remaining high with no additional checks - should have been reported to the physician. The Hospitalist said he would have directed care based on his clinical opinion of what to do. The Hospitalist said that the nurses should have called for direction for any abnormal values. The Hospitalist said Patient #1 was not stable while being transported to the PACU for surgery with a high heart rate, low blood pressure and critical value blood sugar and not acting normally.

Based on review of documentation,the root causes analyses and plan of correction and interviews, the Hospital failed to ensure that the nursing staff developed and kept current, a nursing care plan for the management of Patient #1's abnormal blood sugar.

Findings included:

1) Please refer to Tag A 3952 for specific information.