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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to provide nursing services within recognized standards of practice when a patient experienced a change of condition. Specifically, the facility failed to ensure nursing staff provided nursing care and services according to the patient's condition, physician orders, facility policies and within recognized standards of practice for patients who experienced hypoglycemia (low blood glucose) or hyperglycemia (high or elevated blood glucose) in two of three patient records reviewed. (Patient #1 and Patient #3)

Based on interviews and document review, the facility failed to provide nursing services within recognized standards of practice when a patient experienced a change of condition. Specifically, the facility failed to ensure nursing staff provided nursing care and services according to the patient's condition, physician orders, facility policies and within recognized standards of practice for patients who experienced hypoglycemia (low blood glucose) or hyperglycemia (high or elevated blood glucose) in two of three patient records reviewed. (Patient #1 and Patient #3)

Findings include:

Facility policies:

The Medication Ordering policy read, medication orders require evidence of a diagnosis, condition, or indication for use for each medication ordered. Medication orders must include the drug name, strength, dosage, frequency, route of administration, and indication. All medication orders require an indication (the reason/purpose for the medication).

The Medication Ordering policy read, the required action to be performed by the Registered Nurse (RN) when administering medications, include: Obtain the correct medication. Administer medications within the appropriate time frame indicated on the medication order. The patient must be observed by the RN when the medication is administered. The RN is expected to document when medications are administered to the patient in real-time. Questions regarding medication orders, dosages and alternate treatments are to be reviewed and clarified with the prescribing practitioner. Additionally, patient responses and/or reactions to medications must be documented. The physician must be notified if the patient's symptoms are not relieved by the highest dose of the medication ordered or if the patient experiences an adverse reaction to a medication.

The Critical Results/Values Notification and Documentation policy read, critical test results or values may be imminently life-threatening. Critical results require immediate notification to the healthcare provider. Texting is not an acceptable form of communicating critical results as there is no verification the message was received. Critical test results are communicated within 30 minutes of the result to the responsible healthcare provider.

References:

According to the facility's Laboratory Critical Values document, a critically low glucose level was less than or equal to 40 milligrams per deciliter (mg/dl), and a critically high glucose level was greater than or equal to 500 mg/dl.

The Lippincott Guidance for Safe Medication Administration Practices, provided by the facility, read, the registered nurse (RN) is responsible to verify all patient medication orders contain a medical condition or a reason the patient is to be administered the medication. The RN ensures medication orders indicate when medications are to be administered and the dosage of the medication aligns with the patient's current condition. The RN is to be knowledgeable about all medications administered to patients, aware of the known adverse effects the medication has, capable of identifying potential medication errors and qualified to administer the medication to the patient.

1. The facility failed to ensure nursing staff provided care for patients with hypoglycemia and hyperglycemia according to the condition of the patient, the physician's orders, facility policies and nationally recognized standards of care.

a. Patient #1's medical record was reviewed. Patient #1 was admitted on 7/24/22. According to the History and Physical (H&P), Patient #1 presented with chest pain and was admitted for elevated troponins (a protein detectable in the blood as a result of heart muscle damage). Additionally, Patient #1 had a history of type 2 diabetes (a disease in which the body does not produce enough insulin, or becomes resistant to the insulin produced resulting in high blood glucose levels) and rheumatoid arthritis (RA) (joint inflammation and pain disease).

Medical record review revealed on 7/26/22 at 7:07 a.m., Patient #1 had a blood glucose of 228 mg/dl (reference range according to the medical record was 70-199 mg/dl). At 9:30 a.m., Patient #1 was administered 40 mg of prednisone (a medication used to decrease joint inflammation) according to the medication administration log.

On 7/26/22 at 11:37 a.m., two hours and seven minutes after Patient #1 was administered 40 mg of prednisone, Patient #1's blood glucose was documented at 380 mg/dl. At 12:54 p.m. Patient #1's blood glucose was rechecked and Patient #1 had a blood glucose of 492 mg/dl. At 12:59 p.m., Patient #1 was administered 14 units of insulin. Subsequently, at 1:38 p.m., Patient #1 was discharged from the facility.

Patient #1's medical record review revealed no evidence that Physician #2 had was notified when Patient #1's blood glucose was 380 or 492 on 7/26/22.

i. On 10/19/2022 at 4:08 p.m., an interview was conducted with Physician #2. Physician #2 stated Patient #1 experienced an RA flare-up (worsening of the inflammation, swelling and pain associated with RA) while hospitalized. Physician #2 stated prednisone was administered to treat the flare-up. Physician #2 stated prednisone increased insulin resistance in diabetic patients and caused the potential of blood sugar (blood glucose) levels to become severely elevated.

Physician #2 stated Patient #1 was prescribed insulin while hospitalized. Physician #2 stated the medication orders for insulin outlined the amount of insulin to administer to the patient based on the blood glucose level of the patient. Physician #2 stated he expected to be notified of blood glucose levels at or above 300 mg/dl.

The medical record for Patient #1 was reviewed by Physician #2. Upon logging on to the electronic medical record, Physician #2 reviewed with the surveyor an order created on 7/24/22 at 8:48 p.m. for insulin lispro (short-acting insulin). The order included instructions to contact the physician if the blood glucose was above 300 mg/dl.

However, review of Patient #1's medical record provided by the facility revealed the same medication order for insulin, however, there was no documentation instructing to call Physician #2 if Patient #1's blood glucose was greater than 300 mg/dl.

ii. On 10/18/22 at 3:35 p.m., an interview was conducted with RN #4 who stated medical providers entered a hypoglycemia order set for patients prescribed insulin. RN #4 further stated a hyperglycemia order set did not exist to clarify and outline what nursing care and medication treatment were required for patients who became hyperglycemic. RN #4 then stated communication with the patient's medical provider was required for blood glucose levels over 399 mg/dl.

b. Patient #3's medical record was reviewed for hospitalizations on 2/23/22 and 8/26/22. Medical record review revealed Patient #3 was a type 1 diabetic (elevated blood glucose levels resulting from an inability of the body to make insulin) and had been admitted with diabetic ketoacidosis (DKA) (a buildup of acids in the blood as a result of a lack of insulin).

On 8/26/22 at 8:46 p.m., hypoglycemia orders were entered for Patient #3. According to the hypoglycemia orders, dextrose (a medication used to treat very low blood glucose ) was to be administered for hypoglycemia events for blood glucose levels less than or equal to 70 mg/dl. Blood glucose levels had to be checked 15 minutes after hypoglycemia orders were initiated. The process was to be repeated until the blood glucose level was greater than or equal to 70 mg/dl. After the hypoglycemia was treated, the medical provider was to be notified to review insulin administrations and adjustments.

Medical record review revealed on 8/29/22 at 5:05 p.m., Patient #3 had a blood glucose level of 37 mg/dl, which was indicated in the medical record as a critically low value. A repeat blood glucose test was performed at 5:32 p.m. Patient #3's blood glucose was 57 mg/dl, which was indicated as a low value. The provider was documented as notified of the low blood glucose levels. Further review revealed 28 minutes later, at 6:00 p.m. Patient #3's blood glucose was 113 mg/dl.

At 6:52 p.m., the RN administered 6 units of insulin to Patient #3 and Patient #3 did not have food intake at the time the insulin was administered. According to the medication order for insulin, the "No Calories or NPO (nothing by mouth)" table was to be followed for insulin dosing. Furthermore, the No Calories table stated for blood glucose levels between 100 - 179 no insulin was to be administered.

Further review of Patient #3's medical record revealed the RN had not administered the insulin according to the medication order.

At 9:18 p.m., Patient #3 became hypoglycemic with a blood glucose level of 67 mg/dl.

i. An interview was conducted with RN #5 on 10/19/22 at 10:57 a.m. RN #5 stated facility policy and guidelines instructed a change in patient condition occurred when a patient became hyperglycemic or hypoglycemic. RN #5 stated medical providers were required to be notified when a patient became hyperglycemic or hypoglycemic. RN #5 stated documentation was placed by the nurse in the patient's medical record after communication occurred with the medical provider. RN #5 stated the medication order for insulin outlined how much insulin to administer to the patient. RN #5 stated hyperglycemic and hypoglycemic events could cause a patient to become comatose and even lead to death.

ii. On 10/19/2022 at 12:14 p.m., an interview was conducted with nurse manager (Manager) #1. Manager #1 stated hyperglycemia and hypoglycemia were considered a change in the patient's condition. Manager #1 stated elevated and low blood glucose levels should have been reviewed with the medical provider who oversaw the patient's care. Manager #1 stated nursing staff were required to monitor low blood glucose levels. Manager #1 stated patients with extremely low blood glucose levels could become unconscious, experience organ damage and organ failure, and were at risk of dying. Furthermore, Manager #1 stated patients experiencing hypoglycemia and hyperglycemia were prone to negative patient outcomes.