HospitalInspections.org

Based on clinical record review, patient interview and staff interview the facility failed to ensure that the Registered Nurse evaluated the care of 1 (#2) 3 patients sampled who had physician orders for blood sugar testing as evidence by failure to document blood sugar testing as ordered by the physician.

The findings include:

Interview with Patient #2 on 3/22/18 at 10:00 a.m. revealed that "staff did not check blood sugars like they were supposed to." Clinical record review shows that the patient had a physician order, dated 1/14/18, to check the patient's blood sugar twice a day.

On 3/22/18 at approximately 10:40 a.m. the nursing supervisor provided the clinical record documentation of the patient's blood sugar checks and it was reviewed. The record shows that for the month of January 2018 the patient's blood sugar is not recorded as being checked on 1/16/18, 1/21/18, 1/24/18, 1/27/18, 1/29/18, 1/30/18, and 1/31/18.
For the month of February 2018 the patient's blood sugar is not recorded as being checked on 2/15/18, 2/20/18, 2/23/18, 2/24/18, 2/25/18, 2/26/18 and 2/27/1018.

The patient's blood sugar was only checked and recorded once a day on 1/17/18, 1/18/16, 1/20/18, 1/22/18, 1/25/18, 1/26/18, 1/28/18, 2/1/18, 2/3/18 and 2/4/18.

The hospital staff failed to follow the physician order to check the patient's blood sugar twice a day.