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Based on medical record review and interview the facility failed to ensure nursing staff had adequate knowledge and training to provide care to diabetic patients resulting in the harm of 1 of 1 patients (#8). Findings include:

1. Failure to ensure staff had appropriate training and knowledge for the care of a diabetic patient. (see tag A386)

Based on medical record review and interview the facility failed to ensure nursing staff had adequate knowledge and training to provide care to diabetic patients resulting in the harm of 1 of 1 patients (#8). Findings include:

On 5/6/2014 at approximately 1530 a review of the adverse events log was conducted. Three occurrence reports were noted with the same patient (patient #8) three consecutive days in a row on 2/2/2014, 2/3/2014, and 2/4/2014. The patients chart was requested for review.

On 5/6/2014 at approximately 1555 a review of patient (#8) medical record revealed that they were admitted to the behavioral unit on 1/31/2014 at 2325. The patient's history and physical noted the patient's medical history included diabetes mellitus, hypertension, congestive heart failure, and brain injury. The patient was admitted to the behavioral unit with the psychiatric diagnosis of schizophrenia (paranoid type). The laboratory value included on admission on the history and physical noted a glucose fasting level of 47 as "elevated".

On 2/1/2014 at 0035 capillary blood glucose level checks were ordered to be checked before meals and at bedtime. Blood glucose checks were documented on 2/1/2014 as 174 at 0625, 230 at 1200, and 241 at 1659 and no blood glucose check was documented at bedtime.

According to the first incident report on 2/2/2014 at 0015 the patient was found lying by the door at the entrance of the patient's room. The patient's blood glucose level at that time was documented as 283. The occurrence report noted that the patient was on fall precautions with recommendations for close monitoring of patient, use of assistive device (wheelchair) and for the patient to call for assistance as needed. The patient was documented as delusional according to the physician's note on the occurrence report dated 2/2/2014 at 0107.

On 2/2/2014 the capillary blood glucose readings included a lab result of 174 at 0822 but did not have a recorded blood glucose level performed on the floor. The next blood glucose level recorded as obtained from staff was at 1728 with a result of 143. The blood glucose level at 2206 was 203. On 5/7/2014 at approximately 0930 staff D was asked if documentation was correct and could they provide documentation where the patient's blood glucose levels were checked by the staff prior to administration of insulin. Staff D stated the lab result was probably used for the glucose level prior to the administration of insulin for the morning scheduled medication. Staff D then confirmed documentation did not exist for the blood glucose check at lunch time.

On 2/2/2014 at 0800 the patient's vital signs were obtained. The patient's blood pressure was documented at 86/65. According to the patient's medication administration record on 2/2/2014 at 0957 the patient was administered 10 mg of Lisinopril, 5 mg of amlodipine, and 60 units of levemir. On 2/2/2014 at 1122 the social worker documented the patient as being unable to respond to questions because the patient was in a "catatonic state" . On 5/7/2014 at approximately 0930 staff D was asked if the nurse administering the anti-hypertensive medication (Lisinopril and Amlodipine) should have questioned administration of the medications and contacted the physician due to the patient's (low) blood pressure. Staff D stated, "yes, (they should have). "

On 2/3/2014 at 0932 the second occurrence occurred with patient #8. The patient was documented as sliding out of his wheelchair. The medical assessment of the patient from the physician stated the patient " was getting up from (his) wheelchair and fell down on his buttock." On 2/3/2014 the patient's recorded blood glucose checks were 119 at 0608, 81 at 0925, no blood glucose level recorded for his check prior to lunch, a refused blood glucose check was documented at dinner time, and a blood glucose of 305 at 2102 and 2200. On 2/3/2014 at 0918 the patient was administered 10 mg of Lisinopril and 5 mg of amlodipine. On 2/3/2014 at 0947 the patient was administered 60 units of levemir. On 5/7/2014 at approximately 0930 staff D was queried if the nurse administering the medication should have questioned the administration of levemir and contacted the physician with the patient's blood sugar being documented at 81. Staff D responded "yes, (they should have)" .

On 2/3/2014 at 2219 the patient was administered 60 units of levemir.

On 2/4/2014 at 0753 the patient's blood glucose from the lab was 47. Critical results were called to the nurse on the behavioral unit. A capillary blood glucose was checked on the floor on 2/4/2014 with the result of 42. Orange juice was administered and the patient's blood glucose was rechecked with a result of 35. Orange juice was again administered and the patient's blood glucose was elevated to 72. On 2/4/2014 at 0913 the patient was administered 60 units of levemir, 10 mg of Lisinopril, and 5 mg of Amlodipine. On 2/4/2014 at 1029 the patient's blood pressure was recorded as 82/64. On 5/7/2014 at approximately 0930 staff D was queried as to whether the nurse should have questioned administration of the levemir and contacted the physician. Staff D stated, "yes, (they should have)". Staff D was then asked should the nurse have administered the anti-hypertensives without knowing the patient's blood pressure. Staff D responded, "no, (they should have not administered) " .

On 2/4/2014 at 1237 the patient's blood glucose was recorded as 155 and was administered 2 units of Humalog.

On 2/4/2014 at approximately 1650 a code blue was called due to the patient being found unresponsive with "fixed pupils and constricted." The patient's blood glucose was checked at the bedside with a result of 98. Blood was obtained from the patient at 1710 and sent to lab for stat results. The patient was intubated at 1740. At 1750 the patient's blood glucose was resulted and called to the floor. The patient's blood glucose result was 22. The patient received an infusion of dextrose 50 at 1752. The patient was then transferred to the intensive care unit.

The patient was transferred to another facility for needs of a higher level of care on 2/7/2014 at 1800. According to the patient progress note dated 2/7/2014 at 1847 the patient's primary diagnosis was "acute altered mental status change secondary to hypoglycemic insult possible hypoxic encephalopathy." The patient at the time of transfer was unable to respond to stimuli.

On 5/7/2013 at approximately 1300 staff D was asked if nurses on the behavioral unit were competent to care for patients with medical conditions. Staff D stated, "they are psych (psychiatric) nurses and need to be crossed trained on the med/surg unit" and "I have four nurses currently cross training on the med/surg unit." When asked if caring for a psychiatric patient shouldn't the nurses be aware of how to care for a diabetic patient, staff D responded, "yes." When asked what type of education nursing had for caring for diabetic patients staff D presented two information sheets on hypoglycemia and hyperglycemia. Staff D was unable to verify staff had received the information and stated, "we hung these in the nursing areas where staff sit."

On 5/7/2014 at 1330 staff D was asked to provide competency training for nurses on hypoglycemic / hyperglycemic events. Staff D provided competency documentation for nursing at which time only addressed the nurse's competency to do glucometer (blood glucose) testing.

Based on observation, document review and interview, the facility failed to ensure that the Dietician was responsible for the daily management and activities of the Dietary Department resulting in the potential for substandard food being served to all patients at the facility. Findings include:

On 05/06/2014 from 1000-1115, a tour of all areas of the dietary department was conducted with the Registered Dietician (staff F) revealing the following:
1. Review of a "Daily Food Temperature Log" for first five (5) days of May 2014 contained documentation of the PM (afternoon) temperatures between 42 degrees-45 degrees Fahrenheit. A second log (for another refrigerator) was reviewed and contained documentation of PM temperatures for May 2014. Of the five days recorded in May, only one (1) of five (5) PM temperatures was recorded as 40 degrees or below. The bottom of the log contained a statement that read "Refrigerator temperature should be 40 degrees Fahrenheit or less. Corrective Action: Report issue to Kitchen Manager immediately to generate a work order." Of the two documents and documentation of ten (10) temperatures for the PM shifts, only one was within a safe storage range of 40 degrees Fahrenheit or below.

At the time of the observation, staff F was queried as to what was supposed to be done if a temperature was found to be out of the appropriate temperature range? Staff F replied, "the staff are supposed to contact me, I have a cell phone and a pager and am available by both anytime." When queried as to if she had received any reports from staff about the refrigerator temperatures being out of range, staff F replied, "No, I have not."

During the tour above on 05/06/2014 from 1000-1115 with staff F, all of the refrigerator and freezer areas were observed. In several of the refrigerators there was opened food without dates and pans of left-over foods that were outdated by the date listed on the stickers on them. Additional observations included:
1. Opened bag of shredded lettuce-not dated and turning brown in color.
When staff F was queried about the item she stated, "staff are supposed to date items when they open it." She also confirmed that the lettuce was turning brown and removed it from the area.
2. One large pan of jello with fruit that contained a sticker with a "use by" date of 5/4. When queried about the date staff F replied, "yes, that is May 4th and should have been removed"
3. One pan of diet jello that contained a sticker that read "4/30 good until 5/5." Staff F again confirmed that the jello should have been removed.
4. One pan of roast beef with a sticker that read 5/3 and a use by date of 5/11. Staff F was queried as to how long the food could be kept available for use she stated, "I believe it is up to six (6) days." When queried further about the date on the roast beef indicating that it was good for up to nine (9) days she stated, "staff did not do that right." On the same shelf was a pan of pork lion that contained a sticker of 4/29 and "use by" date of 5/7 again indicating that the meat was good for up to nine (9) days in the refrigerator.

On 05/06/2014 at 1115 during an interview with staff F (Registered Dietician), revealed that she was the staff member responsible for the entire workings of the dietary department. Staff F also stated, "I think that the refrigerator temperatures are incorrect and have bought new thermometers for the refrigerators." Explained to staff F that if she has doubt about the temperature readings than she needs to address them immediately to ensure the food is safe for the patient consumption.

On 05/07/2014 at 0900 a review of dietary policy revealed the following:
"Food Preparation Standards, Policy NO: 25, Effective Date: 01/01/2003, Reviewed Date: 9/09, Administrative Approval: 10/8/12, Procedure: (bullet #9), Foods will be held below 40 degrees Fahrenheit..."
"Food Storage, Policy No: 24, Effective Date: 01/01/2003, Reviewed Date: 9/09, Administrative Approval: 10/8/12, Procedure: (bullet #7) Perishable foods are stored at appropriate temperature ranges, (bullet #8) A daily temperature log is maintained for all refrigeration units by the a.m. and p.m. supervisors, (bullet #12) All foods are stored after opening and are covered, labeled and dated. Left over foods will be utilized or discarded within three days or frozen for future use."

On 05/07/2014 at 1400, a follow up interview was conducted with staff F to discuss the findings of the policy review. When staff was informed that the policy states that foods can be kept up to three (3) days she stated that she was "unaware of that time frame." Staff F also stated that she has, "only been employed here for a short time. I am working on things."

Based on document review and interview, the facility failed to ensure that the therapeutic diet manual was approved by the Medical Staff resulting in the potential for unmet dietary needs for all patients being treated at the facility. Findings include:

On 05/06/2014 at 1500 during review of the Diet Manual, revealed that the manual did not contain evidence that it had been approved by the Medical Staff.

On 05/07/2014 at 1100 during an interview with staff F, the Dietician, when queried if the diet manual had been approved by the Medical Staff she replied, "not to my knowledge."

Based on interview, the facility failed to ensure that a therapeutic diet manual was readily available for Nursing and Medical Staff resulting in the potential for unsafe dietary practices for all patients being treated at the facility. Findings include:

On 05/06/2013 at 1100 during interview with the Dietician, revealed that the only available therapeutic diet manual is located in her office. When asked if Nursing Staff or Medical Staff have access to therapeutic diet manuals on the patient units she stated, "not to my knowledge".