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Based on review of hospital protocol, closed medical records, and staff interviews nursing failed to appropriately assess and communicate a change in the patient's condition in 2 of 7 patients. (# 4 and #3).

Findings include:

1. Medical record review of patient #4 revealed a 59 year-old male under involuntary commitment admitted to the hospital on 4/11/2009 at 0028 with a diagnosis of Schizophrenia with acute exacerbation, Diabetes Mellitus, chronic renal failure and hypertension. Record review revealed physician orders, dated 4/11/09 at 1105, for finger stick blood sugars (FSBS) "four times a day before meals and at bedtime." Record review revealed FSBS results and insulin administered as ordered by the physician. Record review revealed a FSBS on 4/12/09 at 0830 of 27. Review of nursing documentation revealed "Gave patient orange juice few minutes later check it had come up." Record review revealed nursing did not communicate to the physician the decrease in blood glucose until 1613 on 4/12/09.

Medical record review of nursing documentation dated 4/13/09 at 0153 revealed "patient has been monitored frequently this tour due to his state of lethargy. He has been sleeping a lot and is a bit difficult to arouse verbally." Review of nursing documentation revealed assessment of pulse and blood pressure on 4/13/09 at 0153 but no assessment of blood sugar and no communication with physician of change in patient's mental status. Medical record revealed that the patient was found unresponsive in bed on 4/13/09 at 0825 and FSBS was 34.

Interview on March 3/18/2010 at 1130 with administrative staff revealed that at the time of patient #4's admission to the hospital's behavioral unit there was no guidance for nurses to communicate to the physician the monitoring of a diabetic patients. Interview revealed "nurse should have called" the physician.



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2. Medical record review of Patient #3 revealed a 57 year old admitted on 1-7-2010 for a diagnosis of Gastrointestinal Bleeding. Record review revealed the physician ordered the patient to receive blood transfusions. Record review revealed on 1-9-2010 the patient's blood pressure (BP) prior to the start of the blood transfusion at 2100 ranged from 128/78 to 100/67. Record review revealed the patient's BP at 2100 was 109/62. Further review revealed at 2115 the patient's BP was 98/64, at 2145 the BP was 96/56, at 2244 the BP was 96/60 and at 2335 the BP was 95/62. Record review revealed no documentation the physician was notified of the decrease in the patient's BP.

Interview with administrative nursing staff on 3-18-2010 at 1345 revealed the staff should have notified the physician of the decrease in the patient's blood pressure. The interview revealed there was no documentation available of the staff notifying the physician of the decrease in the patient's blood pressure during the blood transfusion.

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NC00062240