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Based on document review and interview, it was determined for 1 of 5 (Pt #1) patient presenting to the Emergency Department (ED) with the Chief Complaint of Hypoglycemia, the Hospital failed to ensure ED policies and/or procedures for reassessment of hypoglycemic patients were established and followed. This has the potential to affect all hypoglycemic patients who present to the ED.

Findings include:

1. Pt #1's record was reviewed on 9/13/16 at approximately 12:30 PM. Pt #1 presented to the ED on 7/29/16 at approximately 11:29 AM with the Chief Complaints of Hypoglycemia and Altered Mental Status.
a. ED physician documentation stated Pt #1's blood glucose at the nursing home was 50 (Hospital's normal blood glucose range 60 - 100 mg/dl - milligrams per deciliter) and was given one ampoule (amp) of Dextrose 50% (D50 intravenous- IV) by ambulance personnel with a follow up blood sugar of 314.
b. ED nursing documentation stated the following:
1) At 1:37 PM, Pt #1 was triaged by ED Registered Nurse (RN) (E#4) and at 1:41 PM, Pt #1's blood glucose level was 151. At 1:46 PM, E#4 stated "pt refusing to drink orange juice. only (not capitalized in quotation) took very small amount". Care was handed off to ED RN (E#5)
2) At 2:12 PM, laboratory tests were drawn and Pt #1's blood glucose level of 126.
3) At 4:30 PM, E#5 stated "... family states... (Pt #1) is not back to baseline... is normally alert, oriented and very sharp and witty." Patient is currently alert and oriented x (times) 2- not oriented to place, mumbling and at times not making sense.
4) At 7:35 PM, ED RN (E#6) stated "Pt family concerned of pt's decreased LOC (level of consciousness), blood sugar checked 37".
5) At 7:44 PM and 8:12 PM, one amp of Dextrose 50 was given IV at each time by E#6.
6) At 8:10 PM, a liter of Dextrose 10% was started at 75 ml per hour IV.
7) At 8:37 PM, Pt #1's blood glucose level was 264.
8) The record lacked documentation reassessment of Pt #1's blood glucose level for approximately 5 hours and 23 minutes.

2. On 9/13/16 at approximately 2:30 PM, an interview was conducted with the ED Manager (E#2). E#2 stated the "ED doesn't have a Hypoglycemia protocol, only the Hospital inhouse has one. My practice would be at least hourly (to check the blood glucose- BGM) and that's what I would expect..."

3. On 9/14/16 at approximately 3:20 PM, a phone interview was conducted with E#4 with the Administrative Coordinator/Risk Manager (E#1) present. E#4 agreed with E#2's interview and stated "I would recheck it (BGM) at least hourly or more often if needed."

4. On 9/15/16 at approximately 9:10 AM, an interview was conducted with the ED Medical Director (Medical Doctor- MD#3). MD#3 stated "No, I don't know of a policy for the ED, but yes, I would expect a follow up on the blood sugar at least hourly although the hourly patient check could tell the story (if alert, talkative, eating, drinking, lethargic, not responding). "

5. On 9/15/16 at approximately 10:05 AM, an interview was conducted with E#6. E#6 stated "...(E#5 had just called report... I went in to introduce the transporter to the patient (Pt #1) and the family and to take ... (Pt #1) upstairs. The family said ... (Pt #1) wasn't right and had a decreased level of consciousness so I did a blood sugar and it was 37. We gave an amp of D50 (Dextrose 50) and ... MD#1 decided to have a 2nd amp given because ... (Pt #1)'s sugar was so low... I would check (BGMs) on patients who come in with Hypoglycemia at least hourly unless they were alert and eating or drinking. "

Based on document review and interview, it was determined the Hospital failed to ensure contract/agency personnel orientation and competency were completed for 4 of 5 (E#5, E#7, E#8, and E#9) ED contract/agency Emergency Department Registered Nurses (ED RNs) and failed to ensure a 30 day evaluation was completed for 5 of 5 (E#5, E#7, E#8, E#9, and E#10) ED RN contact/agency nurses. This has the potential to affect all patients serviced by the ED with a current average daily census of 66.

Findings include:

1. The Hospital policy titled "Contract/Agency Employees" was reviewed on 9/15/16 at approximately 1:15 PM. The policy stated "These employees must meet the orientation requirements for the particular job classification as well as any other mandated qualifications ...2. 30 Days of service review completed by the department director/manager or supervisor ... 4. The director/manager will forward all documentation pertaining to the contract/agency to HR (Human Resources) evaluations, completed comp (competency) tools, net learning transcripts, etc (etcetera) ..."

2. The ED RN Registry list for September 2015 to September 2016 was reviewed on 9/15/16 at approximately 1:00 PM. The list stated the Hospital had utilized 13 Registry ED RNs during this timeframe, with four currently being utilized. One recent and four current ED RN contract/agency personnel files were reviewed and lacked the following:
a. E#5 Date of Contract: 5/23/16 to 8/29/16.
E#5's file lacked ED orientation/competencies and a 30 day evaluation.
b. E#7 Date of Hire (DOH): 7/5/16.
E#7's file lacked ED orientation/ED competencies and lacked a 30 day evaluation.
c. E#8 DOH: 7/5/16.
E#8's file lacked ED orientation/ED competencies and lacked a 30 day evaluation.
d. E#9 DOH: 8/1/16.
E#9's file lacked ED orientation/ED competencies and lacked a 30 day evaluation.
e. E#10 DOH: 8/1/16.
E#10's file lacked a 30 day evaluation.

3. An interview was conducted with the Administrative Coordinator/Regulatory Compliance (E#1) on 9/15/16 at approximately 12:00 PM. E#1 stated "We cannot find any of ... (E#5) ED orientation or competency forms... and there isn't a 30 day evaluation. I don't think they (the ED Manager -E#2 and the ED Contract Leader (interim Director)- E#3) were aware we needed to do this and both are new to their positions. (E#2- 15th of August; E#3- 22nd of August)."

4. An interview was conducted with the E#2 and E#3 on 9/15/16 at approximately 2:00 PM. Both concurred with E#1's interview and stated "We didn't realize these (orientation, competencies, and 30 day evaluations) weren't done. We thought they were in HR (Human Resources)."