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Based on record review and interview, it was determined that facility staff failed to follow physician orders.

Findings were:

Facility policy entitled " Physician Orders: Receiving, Transcribing " stated the following: " Policy - Prompt and accurate transcription of the physician orders facilitates delivery of quality patient care ...Purpose - To outline the responsibilities in receiving, transcribing and noting of physician orders ...1. Orders written on the physicians order sheet will be acknowledged as soon as possible. "

Review of patient #1's medical record on 10/29/12 revealed the following:
- A " Physician Orders " sheet indicated that blood glucose checks " AC&HS " (before meals and at night), and an insulin sliding scale were ordered on 7/9/12 at 4:21 PM.
- The patient ' s " Point of Care Testing " notes and medication administration records revealed the following: On the night of 7/9/12 no evidence of a blood glucose check was evident; according to the physician orders the patient should have had a blood glucose check that night.
- On the morning of 7/10/12 at 7:10 AM the patient ' s blood glucose level was documented as 179 and no insulin was administered; according to the physician orders the patient should have received 2 units of insulin.

The above findings were confirmed in an interview with the Risk Manager on 10/29/12.

Based on record review and interview, it was determined that the facility failed to ensure that nursing staff accurately documented notes in the medical record.

Findings were:

Facility policy entitled " Daily Documentation (Nursing Notes) " , reviewed on 10/29/12, stated the following: "Policy - Nursing documentation will be done each shift with reassessments occurring at change of shift, change of caregiver, change in condition, prn or per physician ' s order ...1. Daily assessments and/or reassessments will be done at change of shift, change of caregiver, change in status, prn or per physician ' s order. An RN must do an assessment/reassessment on patients at least every 24 hours. "

Review of patient #1's record on 10/29/12 revealed that a nurse inaccurately documented patient discharge information in the medical record:
- The " Discharge Assessment: Discharge Summary " dated 7/11/12 at 10:47 AM indicated that the patient ' s mode of discharge was by a " Wheelchair " .
- A " Clinical Documentation-Nursing Note " dated 8/20/12 at 10:56 AM stated the following " It was noted in the discharge instructions that patient left via wheelchair because instructions were completed in computer before patient decided to get copy of labs. Patient left unit walking as he was directed to medical records to request desired information. "

The above findings were confirmed in an interview with the Risk Manager on 10/29/12.