HospitalInspections.org

Based on record review and interview, registered nursing staff failed to supervise and evaluate the nursing care for 1 of 1 patient (Patient #5). Although nursing staff was aware of Patient #5's severely fluctuating blood sugar level, Patient #5's blood sugar level was not monitored according to physician orders.

Findings included:

Patient #5's Physician Orders dated 02/12/15 at 19:11 reflected blood sugars were to be checked before meals and at bedtime and "prn [whenever necessary] per patient request."

The Admission Nursing Assessment dated 02/13/15 at 00:05 noted the patient's high blood sugar level of 437 mg/dL. The document noted Patient #5 suffered from low and high blood sugar levels.

Nursing documentation dated 02/14/15 at 07:30 reflected the patient "complained of needing blood sugar checked at 06:45." Late entry nursing documentation dated 02/14/15 at 15:00 noted nursing staff checked Patient #5's blood sugar "at 07:05 following report." The patient's blood sugar was 49 mg/dL.

The Medication Administration record revealed Patient #5's blood sugar levels were scheduled to be checked at 06:30, 11:00, 16:00, and 21:00.

Nursing long-term goals dated 02/12/15 reflected that the patient's blood sugar levels would be controlled between 70 and 120 mg/dL.

Hospital Employee #1 agreed during an interview on 06/17/15 at 14:44 that nursing staff finished report first before Patient #5's blood sugar was measured.

Hospital Nursing Employees #5 was interviewed on 06/17/15 at 14:55 and stated he would interrupt report if a patient complained of changes in blood sugar level.

Hospital Employee #2 stated on 06/17/15 at 15:50 that "the report should have stopped" and Patient #5's blood sugar level should have been checked at 06:30.

Hospital Nursing Employee #10 stated during a phone interview on 06/18/15 at 09:24 that Patient #5 needed her blood sugar checked at 06:30 that day. Instead, the nurses "did continue with their report."

The hospital's Policy entitled, "Blood Glucose Monitoring POC 107" dated 06/2014 reflected. "In case a patient experienced high or low blood sugar levels...quality care dictates a STAT [immediate] test."