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Based on interviews and record review, facility staff failed to recheck a potassium level after IV (intravenous) potassium was completed per facility policy in 1 (Patient #1) of 10 patients; failed to provide a complete nursing handoff report for 1 (Patient #1) of 10 patients; failed to administer an insulin drip per physician order and facility policy for 1 (Patient #1) of 10 patients; and failed to assess and monitor for changes in condition in 1 (Patient #1) of 10 patients in a total sample of 10 medical records reviewed.

Findings include:

Staff failed to recheck a potassium level after IV potassium was completed per facility policy and failed to assess and monitor for changes in condition. See tag A-0395.

Staff failed to provide a complete nursing handoff report and failed to administer an insulin drip per physician order and facility policy. See tag A-0405.

Based on interviews and record review, facility staff failed to recheck a potassium level after IV (intravenous) potassium was completed per facility policy in 1 (Patient #1) of 10 patients and failed to assess and monitor for changes in condition (blood sugars) in 1 (Patient #1) of 10 patients in a total sample of 10 medical records reviewed.

Findings include:

A review of Patient #1's medical record revealed Patient #1 presented to the facility's Emergency Department on 04/09/2024 at 9:06 AM with a chief complaint of nausea, chest heaviness and a headache. Patient #1's history and physical revealed Patient #1 had a history of Type 1 Diabetes Mellitus. Further review of the medical record revealed Patient #1's blood sugar was checked on 04/09/2024 and resulted high at 345 mg/DL (milligrams per deciliter; normal limits for persons with Type 1 diabetes is 80-130 mg/DL before meals) at 12:22 PM. Patient #1's potassium level was found to be low, and potassium supplementation was ordered to be completed prior to the administration of insulin. Patient #1 was admitted to the inpatient unit on 04/09/2024 at 4:33 PM where his/her condition declined and was transferred to the ICU on 04/09/2024 at 6:50 PM with a diagnosis of Diabetic Ketoacidosis and a blood sugar critically high at greater than 600 mg/DL.

A review of the facility order set titled, "ED DKA (Diabetic Ketoacidosis) Insulin Infusion" revealed, "Potassium Supplements and follow up labs: potassium CHLORIDE 20mEq (milliequivalents)/100mL (milliliters) IVPB (intravenous piggy back) premix: Potassium: recheck potassium level within 2 hours after total dose of supplements completed...Nursing Orders: Check Metered Blood Glucose (blood sugar): Routine, PRN (as needed), For suspected signs of hypoglycemia, hyperglycemia ..."

A review of the facility's policies revealed that there were no policies or protocols in place in the Emergency Department to ensure critically high blood sugars are followed up on outside of following medical staff order sets.

A review of Patient #1's medical record revealed that "potassium CHLORIDE 20mEq/100mL IVPB premix" was started on 04/09/2024 at 12:34 PM and was completed on 04/09/2024 at 2:30 PM. Review of the medical record revealed Patient #1's potassium level was not checked again until 5:32 PM, over 3 hours after the potassium infusion was completed.

A review of "History of Present Illness" written on 04/09/2024 at 2:53 PM by Endocrine MD L revealed, "...patient presented to the ED this morning with several symptoms in setting of having pump issue supplies. Patient reports administering [his/her] basal insulin prior to arriving to ED, but [s/he] couldn't remember the dose. Our team was consulted close to 3 pm and most recent labs notable for BG (blood glucose) 345 ... This suggests patient is going into DKA, and DKA protocol insulin gtt (drip) ordered...Addition: noted change in patient's condition per chart review after our consultation; patient now in florid (fully developed) DKA and admitted to the ICU. DKA protocol gtt as ordered was not started until [about] 3 hours later ..."

Review of Patient #1's medical record revealed: "Lab Ordered: ... POCT (point of care testing) METERED BLOOD GLUCOSE" was ordered on 04/09/2024 at 3:51 PM by Endocrinology PA P.

A review of Patient #1's medical record revealed there was no evidence additional blood sugars were checked in the Emergency Department past 04/09/2024 at 12:22 PM when Patient #1's blood sugar resulted at 345 mg/DL. Further review of the medical record revealed the next documented blood sugar result was from a lab draw on 04/09/2024 at 5:32 PM and resulted as 615 mg/DL (no time noted when lab was drawn).

A review of "Focus Note" on 04/09/2024 at 6:40 PM revealed, "On call hospitalist notified of change in patient status around 1814 (6:14 PM). STAT was called for increased work of breathing and confusion. Patient admitted for Type 1 DM with hyperglycemia (high blood sugar) 2/2 (secondary to) not using Omnipod pump due to non working controller. Patient started on IVFs (intravenous fluids), electrolyte supplementation and IV ceftriaxone (antibiotic). Insulin gtt was not initiated. Endocrinology was consulted in the afternoon. Recommended initiation of IV insulin DKA protocol. Patient arrived on [Inpatient unit] around 1630 (4:30 PM). Nursing staff noted worsening confusion, increased work of breathing ... A/P (Assessment/Plan): Worsening DKA ... Dispo: Transferring to [ICU] for ongoing case ..."

During an interview on 06/27/2024 at 1:02 PM with ED RN N, when asked about rechecking a potassium level after the potassium infusion was finished, ED RN N stated, "I believe that it should be rechecked after the infusion is done."

An interview was conducted on 06/28/2024 at 2:23 PM with Director of Quality S. When asked to confirm Patient #1's potassium level recheck, Director of Quality S stated, "Potassium Supplementation completed 4/9/24 at 1430 (2:30 PM); Potassium level rechecked 4/9/24 at 1732 (5:32 PM).

During an interview on 06/28/2024 at 2:23 PM with Director of Quality S, when asked about policies on assessing patients in DKA, Director of Quality S stated, "Confirming there's not a policy on assessing DKA and nurses would follow the order set."

Based on interview and record review, the facility staff failed to provide a complete nursing handoff report for 1 (Patient #1) of 10 patients and failed to administer an insulin drip per physician order and facility policy for 1 of 10 patients reviewed (Patient #1) in a total sample of 10 patients reviewed.

Findings include:

A review of Patient #1's medical record revealed Patient #1 presented to the facility's Emergency Department on 04/09/2024 at 9:06 AM with a chief complaint of nausea, chest heaviness and a headache. Patient #1's history and physical revealed Patient #1 had a history of Type 1 Diabetes Mellitus. Further review of the medical record revealed Patient #1's blood sugar was checked on 04/09/2024 and resulted high at 345 at 12:22 PM. Patient #1's potassium level was found to be low, and potassium supplementation was ordered to be completed prior to the administration of insulin. Patient #1 was admitted to the inpatient unit on 04/09/2024 at 4:33 PM where his/her condition declined and was transferred to the ICU on 04/09/2024 at 6:50 PM with a diagnosis of Diabetic Ketoacidosis and a blood sugar critically high at greater than 600 mg/DL (milligrams per deciliter; normal limits for persons with Type 1 diabetes is 80-130 mg/DL before meals).

A review of the facility's policy titled, "KAPS (Keep All Patients Safe)" last revised 05/2024 revealed, "ED (Emergency Department) RN (Registered Nurse) to call inpatient RN for all areas listed below ... Insulin drip and blood sugar checks..."

A review of the facility's policy titled, "Region Medication Administration" last revised 09/18/2023 revealed, " ... Medication Timing: Medications not listed as time-critical care are considered non time-critical. These medications may be administered within 1 hour before or after the scheduled dosing time, for a total window that does not exceed 2 hours ..."

A review of the facility's policy titled, "Region Time Critical Medications" last revised 05/31/2023 revealed that insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion was not listed as a time sensitive medication and would be considered a non-time-critical medication.

A review of "History of Present Illness" written on 04/09/2024 at 2:53 PM by Endocrine MD L revealed, "...patient presented to the ED this morning with several symptoms in setting of having pump issue supplies. Patient reports administering [his/her] basal insulin prior to arriving to ED, but [s/he] couldn't remember the dose. Our team was consulted close to 3 pm and most recent labs notable for BG (blood glucose) 345 [mg/DL] ... This suggests patient is going into DKA, and DKA protocol insulin gtt (drip) ordered...Addition: noted change in patient's condition per chart review after our consultation; patient now in florid (fully developed) DKA and admitted to the ICU. DKA protocol gtt as ordered was not started until [about] 3 hours later ..."

A review of Patient #1's medical record revealed that "Care Handoff: Report given to floor" was completed on 04/09/2024 at 3:32 PM.

A review of Patient #1's medical record revealed, "04/09/2024 at 3:51 PM: Orders Placed [by Endocrinology PA P] ... insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion ..."

A review of the medical record revealed, "Manage Orders: insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion" was acknowledged on 04/09/2024 at 4:39 PM by Inpatient RN M. Further review of the medical record revealed that insulin regular (human) (HumuLIN R) 100 units sodium chloride 0.9% 100 mL infusion was not started until 04/09/2024 at 6:38 PM, three hours after it was ordered.

A review of "Focus Note" on 04/09/2024 at 6:40 PM revealed, "On call hospitalist notified of change in patient status around 1814 (6:14 PM). STAT was called for increased work of breathing and confusion. Patient admitted for Type 1 DM with hyperglycemia (high blood sugar) 2/2 not using Omnipod pump due to non working controller. Patient started on IVFs (intravenous fluids), electrolyte supplementation and IV ceftriaxone (antibiotic). Insulin gtt was not initiated. Endocrinology was consulted in the afternoon. Recommended initiation of IV insulin DKA protocol. Patient arrived on [Inpatient unit] around 1630 (4:30 PM). Nursing staff noted worsening confusion, increased work of breathing ... A/P (Assessment/Plan): Worsening DKA ... Dispo: Transferring to [ICU] for ongoing case ..."

An interview was conducted on 06/27/2024 at 1:02 PM with ED RN N. When asked about the report given to the inpatient unit, ED RN N stated that s/he did not know there was an order for an insulin drip placed and did not report that to the inpatient nurses.

An interview was conducted on 06/25/2024 at 1:35 PM with Endocrine MD L. When asked about Patient #1's insulin drip, Endocrine MD L stated, "Our expectation is that the drip needs to be started when it is ordered, no matter where it is ordered. In patients with DKA, it is better to start treatment sooner than later."

During an interview on 06/25/2024 at 2:20 PM with Manager of Quality B, when asked about order acknowledgement, Manager of Quality B stated, "The expectation is when orders are placed by a doctor, staff are expected to follow through with those orders."

An interview was conducted on 06/25/2024 at 2:30 PM with Inpatient RN M. When asked about the report s/he received, Inpatient RN M stated, "No I did not see the order, and I did not get a report about an insulin drip."

During an interview on 06/25/2024 at 4:10 PM with Inpatient Manager C, when asked about order acknowledgement, Manager C stated, "If you are reviewing and releasing your orders and you acknowledge them, you should have a plan to address the orders."