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Based on interview and document review, the hospital failed to provide adequate nursing services for 1 of 10 patients (P1) reviewed who developed a change in condition with a dangerously elevated blood sugar.

Due to the serious nature of this failure the hospital was unable to ensure adequate nursing services.

Therefore, the hospital was unable to meet the Condition of Participation of Nursing Services at 42 CFR 482.23.

Findings Include:

See A-395: Based on interview and document review, the hospital failed to deliver adequate nursing care based on patient needs for 1 of 10 patients reviewed (P1) when the patient experienced a change in condition, including a blood glucose reading of 670, and nursing staff failed to monitor the patient's vital signs, failed to ensure the medical provider's insulin orders were followed, and failed to ensure the patient avoided food when her blood glucose was dangerously elevated.

See A-408: Based on interview and document review, the hospital failed to ensure verbal orders followed hospital policy and procedures for 1 of 10 patients (P1) reviewed when registered nurse (RN)-R took a verbal order from nurse practitioner (NP)-Q for insulin, but did not document it appropriately. The order was never cosigned by NP-Q, and there was no documentation the patient ever received the insulin.

Based on interview and document review, the hospital failed to deliver adequate nursing care based on patient needs for 1 of 10 patients (P1) reviewed when the patient experienced a change in condition, including a blood glucose reading of 670. Nursing staff failed to monitor the patient's vital signs, ensure the insulin orders were followed, and ensure the patient avoided food when her blood glucose was dangerously elevated.

Findings include:

Medical record review revealed P1's admission occurred on 9/18/18. P1's diagnoses included vascular dementia with behavioral disturbance, and long-standing brittle diabetes type 1. P1's physician's orders dated 9/18/18, included insulin Toujeo Solostar Pen U 300 - 38 units before breakfast, insulin Humalog - 4 units 4 times a day and at bedtime, insulin Humalog 0 - 20 units 4 times a day, before meals and at bedtime per sliding scale, and Accucheck (glucometer) blood glucose testing 4 times per day, before meals and at bedtime.

Progress notes written by registered nurse (RN)-R on 9/22/18, at 12:37 p.m. indicated P1's blood glucose was over 500 by glucometer, the highest reading the glucometer allows. Hospital protocol for such a reading requires a STAT (immediate) order for a serum blood glucose test. The order for the STAT serum blood glucose was placed at 12:42 p.m. A Critical and/or Actionable blood glucose test result of 670 dated 9/22/,18 at 1:47 p.m. was documented as read to RN-R. Nurse practitioner (NP)-Q was notified of the result by RN-R at 1:49 p.m.,one hour and seven minutes after the STAT lab testing was ordered.

Nursing assessment flow sheets dated 9/22/18, were reviewed and revealed P1 ate 75% of her lunch on 9/22/18. No vital signs were documented by nursing that day or during the period from 12:37 p.m. - 3:45 p.m. when she was transferred to ICU (approximately 3 hours) when her blood glucose was recorded multiple times at over 500.

A "Nurse Communication" note from 9/22/18, at 2:08 p.m. written by RN-R was reviewed indicating the following: give an additional 5 units of insulin now. This was not found in physician orders or on the medication administration record (MAR) for 9/22/18, and there was no documentation it was given. There was no evidence of provider review or sign off of the order.

Progress notes, written by RN-R on 9/22/18, at 3:47 p.m. revealed: Accuchecks continue to be elevated since prior to lunch. All readings from the machine on the floor have been over 500. NP-Q has been aware of the situation and she did refer to MD-Y. MD-Y did see patient and put in transfer to ICU. At 3:45 p.m. Last Accucheck prior to leaving continued to be over 500.

Administrative RN-D reviewed P1's medical record with the surveyor on 1/4/18, at 8:15 a.m. She stated it would not be good nursing practice to give a patient food while her blood glucose readings were over 500, when it was unknown how high they really were (the glucometer only reads up to 500). RN-D further stated there was no documentation of vital sign monitoring during this time, and the appropriate nursing intervention would be to monitor vital signs when there is a change in condition, such as severely elevated blood glucose.

During interviews with RN-R on 1/3/19, at 2:40 p.m. and 1/4/19, at 10:45 a.m., she stated that she did not recall if P1 had lunch on 9/22/18, when P1's blood glucose were elevated. RN-R further stated she did not recall whether she gave the 5 units of insulin documented in P1's nurse communication notes, but not in the physician orders or MAR.

During an interview on 1/3/19, at 2:10 p.m. P1's family member (FM)-A stated that she had concerns related to P1's nursing care on 9/22/18. She was concerned that it seemed to take very long for anyone to react to P1's dangerously elevated blood glucose, the lab test took too long to run, and she was concerned she saw RN-R give P1 lunch when P1's blood glucose were over 500. FM-A stated P1 was home now and stable.

The facility policy Standards for Nursing Practice date approved 9/1/17, and provided by hospital staff was reviewed. Under the section: Assessment and Ongoing Care: Vital Signs: Routine vital signs (temperature, pulse, respiration and blood pressure) are assessed and documented upon admission and every 8 hours and as needed with changes in patient condition.

The facility policy titled Orders: Types, Transcription and Implementation of Physician Orders approval date 8/21/17, and provided by hospital staff was reviewed. Under the section: Verbal/Telephone Physician Orders: 1. The use of verbal/telephone orders is discouraged ...3. All telephone/verbal orders will be read back to the prescriber ...5. Orders will be entered into the electronic medical record (EMR) as soon as possible by the receiving professional or designee according to Excellian procedure. This documentation will include: a. The date and time of the order, b. The name and licensure status of the individual giving the order, c. The physician being represented, d. The receiving professional's name and licensure status, e. Select the appropriate designation from the order mode drop down list in the computer which will flag the ordering physician for electronic signature of orders. 6. Telephone or verbal orders must be signed electronically according to requirements of Medical Staff Rules and Regulations.

Based on interview and document review, the hospital failed to ensure verbal orders followed hospital policy and procedures for 1 of 10 patients (P1) reviewed when registered nurse (RN)-R took a verbal order from nurse practitioner (NP)-Q for insulin, but did not document it appropriately. The order was never cosigned by NP-Q, and there was no documentation the patient ever received the insulin.

Findings include:

Medical record review revealed P1's admission occurred on 9/18/18. Her diagnoses included vascular dementia with behavioral disturbance, and long-standing brittle diabetes type 1. P1's physician's orders dated 9/18/18, included insulin Toujeo Solostar Pen U 300 - 38 units before breakfast, insulin Humalog - 4 units 4 times a day and at bedtime, insulin Humalog 0 - 20 units 4 times a day, before meals and at bedtime per sliding scale, and Accucheck blood glucose testing 4 times per day, before meals and at bedtime.

A "Nurse Communication" note from 9/22/18, at 2:08 p.m. written by RN-R was reviewed indicating the following: give an additional 5 units of insulin now. This was not found in physician orders or on the medication administration record (MAR) for 9/22/18, and there was no documentation it was given. There was no evidence of provider review or sign off of the order.

During interviews with RN-R on 1/3/19, at 2:40 p.m. and 1/4/19, at 10:45 a.m. she stated that she did not recall wether she gave the 5 units of insulin documented in P1's nurse communication notes on 9/22/18, but not in the physician orders or MAR.

The facility policy titled Orders: Types, Transcription and Implementation of Physician Orders approval date 8/21/17, and provided by hospital staff was reviewed. Under the section: Verbal/Telephone Physician Orders: 1. The use of verbal/telephone orders is discouraged ...3. All telephone/verbal orders will be read back to the prescriber ...5. Orders will be entered into the electronic medical record (EMR) as soon as possible by the receiving professional or designee according to Excellian procedure. This documentation will include: a. The date and time of the order, b. The name and licensure status of the individual giving the order, c. The physician being represented, d. The receiving professional's name and licensure status, e. Select the appropriate designation from the order mode drop down list in the computer which will flag the ordering physician for electronic signature of orders. 6. Telephone or verbal orders must be signed electronically according to requirements of Medical Staff Rules and Regulations.

Based on interview and document review, the hospital failed to have emergency laboratory services available 24 hours a day in response to patient need for 1 of 10 patients (P1) reviewed, when the patient's blood glucose was elevated above 500 (as high as the meter could detect.) Hospital protocol indicated a STAT (immediate) serum blood glucose, which was ordered, but did not get drawn for 48 minutes. When it was drawn, the patient's blood glucose was 678, and the patient was transferred to the intensive care unit (ICU.)

Findings include:

Medical record review revealed P1's admission occurred on 9/18/18. Her diagnoses included vascular dementia with behavioral disturbance, and long-standing brittle diabetes type 1. P1's physician's orders dated 9/18/18, included insulin Toujeo Solostar Pen U 300 - 38 units before breakfast, insulin Humalog - 4 units 4 times a day and at bedtime, insulin Humalog 0 - 20 units 4 times a day, before meals and at bedtime per sliding scale, and Accucheck blood sugar testing 4 times per day, before meals and at bedtime.

Progress notes, written by RN-R on 9/22/18, at 12:37 p.m., revealed P1's blood glucose read over 500 by glucometer, the highest reader the glucometer allows. Hospital protocol for such a reading requires a STAT order for a serum blood sugar test. The order for the STAT serum blood glucose was placed at 12:42 p.m.

A Critical and/or Actionable blood glucose test result of 670 dated 9/22/18, at 1:47 p.m. was documented as read to RN-R. Nurse practitioner (NP)-Q was notified of the result by RN-R at 1:49 p.m., one hour and seven minutes after the STAT lab testing was ordered.

Progress notes written by RN-R on 9/22/18, at 3:47 p.m. revealed: Accuchecks continue to be elevated since prior to lunch. All readings from the machine on the floor have been over 500. NP-Q has been aware of the situation and she did refer to MD-Y. MD-Y did see patient and put in transfer to ICU. At 3:45 p.m. Last Accucheck prior to leaving continued to be over 500.

During an interview with RN-R on 1/3/19, at 2:40 p.m., she stated it seemed to take a very long time, about an hour, for the lab staff to come and draw the blood for the STAT serum blood glucose that was ordered on 9/22/18. P1 was transferred to ICU, and was alert and oriented at the time of the transfer.

During an interview on 1/3/19, at 1:00 p.m., administrative registered nurse (RN)-I stated that she received a concern related to P1's care on 9/22/18, from the patient representative. RN-I stated she looked into the complaint and found that although a STAT serum blood glucose was ordered for P1 as a result of an accucheck reading of over 500 at 12:42 p.m., the laboratory staff did not draw the blood for that test until 1:30 p.m., 48 minutes after the test was ordered. RN-I stated she filed a patient safety report related to the incident.

During an interview on 1/3/19, at 2:00 p.m. laboratory supervisor (LS)-O stated he was aware of the incident and looked into it. He stated there was only one staff member covering the hospital that day (due to a light duty staff and a sick call), and that person could not respond and draw the blood any faster than she did. LS-O stated the hospital has made some changes since the incident, to ensure all staff working can go onto the floor and provide services as needed. Although the hospital does not monitor the time frames in which STAT orders are completed in any area except the Emergency Department, he was not aware of any other safety incidents related to STAT orders.

During an interview with laboratory director (LD)-P on 1/3/19, at 2:35 p.m. she stated that she was notified of the incident on 9/22/18, with the delay in drawing P1's STAT Serum Blood glucose. She stated that in this instance the hospital could not meet their service level agreement for STAT lab draws due to staffing issues. They did not have the depth of staffing they needed that day. She has since moved staff around to better accommodate patient needs, and are not accommodating light duty staff in that lab. Although the hospital is not monitoring STAT lab times in any area of the hospital except ED, she was not aware of any other patient safety events related to a delay in STAT labs.

During an interview on 1/3/19, at 3:35 p.m., laboratory assistant (LA)-S stated she was the one who drew P1's STAT blood glucose on 9/22/18. She stated she was the only lab assistant drawing blood that day, and she was behind. The census in the hospital was high. Although she knew she had to draw a STAT lab for P1, she could not get to it any faster than she did because she was alone working the floors.

The hospital document Definitions for Test Priority for STAT laboratory tests undated, was reviewed and revealed a STAT order for serum blood glucose in all hospital sites is to be collected within 15 minutes of the order and completed with results available within 30 minutes.