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Based on interview and record review, the hospital failed to ensure the nursing staff checked the blood glucose levels after administering the medications for one of three sampled patients (Patient 1). This failure created the risk of poor health outcomes to the patient.

Findings:

On 2/28/25 at 0930 hours, Patient 1's closed medical record was reviewed with the Director Regulatory Services.

Patient 1's closed medical record showed the patient was admitted to the hospital on 5/26/24.

Review of the H&P examination dated 5/26/24, showed Patient 1 had DM and was on insulin (a medication used to treat high blood sugar).

Review of the Medication Detail showed the physician's order for regular insulin (a short-acting insulin) injection 0-16 units before meals and at bedtime starting on 5/26/24. The instructions included the following:

* If the blood glucose level was less than 70 mg/dL:

- If taking orally and alert, give juice or glucose oral gel or snack/meal.

- Repeat blood glucose and above treatment every 15 minutes until the blood glucose was greater than 80 mg/dL. Once the blood glucose was greater than 80 mg/dL, recheck blood glucose in one hours.

- Review insulin administrations with the physician, obtain additional orders (including when to recheck glucose and for dose adjustment of any scheduled insulin) as necessary. Do not administer any scheduled insulin doses until after consulting physician.

* If the blood glucose level was 201-250 mg/dL, give 8 units regular insulin.

* If insulin coverage was given for bedtime blood glucose POCT and recheck blood glucose POCT four hours later.

Review of the Glucose POCT Device Integrated Values - Adult/Child, the medication administration record, and the patient's meal record showed the following:

* On 5/26/24 at 0841 hours, the patient's blood glucose was 57 mg/dL. At 0842 hours, RN 1 administered dextrose 40% oral gel 15 g (Glutose, a medication used to treat low blood sugar) to the patient. However, there was no documented evidence the nursing staff checked the patient's blood glucose level 15 minutes after administering dextrose 40% oral gel as per the physician's order after

* On 5/26/24 at 0909 hours, the patient's blood glucose was 69 mg/dL. At 0912 hours, RN 1 administered the dextrose 40% oral gel 15 g (Glutose) to the patient. There was no documented evidence the nursing staff checked the patient's blood glucose level every 15 minutes after administering dextrose 40% oral gel as per the physician's order.

* On 5/26/24 at 0942 hours, the patient's blood glucose was 79 mg/dL. The meal record showed the patient consumed 100% breakfast at 1030 hours. There was no documented evidence the nursing staff performed a repeat blood glucose in every 15 minutes per physician's order.

* On 5/26/24 at 1124 hours, the patient's blood glucose was 100 mg/dL.

* On 5/26/24 at 2256 hours, the patient's bedtime blood glucose was 208 mg/dL, and the patient received eight units of regular insulin subcutaneously.

There was no documented evidence the nursing staff checked the patient's blood glucose level four hours later as per the physician's order.

During the concurrent interview, the Director Regulatory Services confirmed the above findings.