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Based on interview and record review, the hospital failed to ensure the nursing staff implemented the hospital's P&Ps for one of two sampled patients (Patient 1) as evidenced by:

1. The nursing staff did not notify the physician when Patient 1's blood glucose level was 306 ml/dL and did not develop the plan of care related to diabetes or dysglycemia for the patient.

2. The nursing staff did not complete the nutritional screening within 24 hours of admission for Patient 1.

3. The nursing staff did not complete the initial pain assessment and did not conduct the pain reassessment after administering the pain medication to Patient 1.

These failures created the increased risk of poor health outcomes to the patient.

Review of the hospital's P&P tilted Assessment/Re-assessment of Patient dated September 2021 showed the following:

* Re-assessment across disciplines is ongoing and occurs at regular intervals during the patient's treatment to determine the response to and effectiveness of the plan of care and interventions.

* The initial assessment on arrival to unit consists of medications, pain assessment including pain goal, a system review of the presenting symptomology and therapeutic intervention, plus any additional sections pertaining to the patient's specific situation. Such assessments should be performed, and the findings documented in the patient's medical record upon receipt of the patient when he/she is admitted to the unit.

* Shift Assessment/Reassessment includes the following:

- Assessment and Documentation shall be completed per unit standard/level of care. The full body system assessment includes a complete physiological assessment must be completed per level of care/unit standard of care at the beginning of each shift and documented by the end of the caregiver shift.

- Pain assessment per Pain Management Policy.

- Additional reassessments may occur for the following reasons: abnormal findings from previous assessment and physician orders.

* For the Med/Surg at Laguna Beach, assessment and documentation will include lab values.

On 12/12/24 at 0957 hours, Patient 1's closed medical record was reviewed with the Nurse Manager.

Patient 1's closed medical record showed Patient 1 came to the hospital on 11/7/24, for a surgical procedure. Patient 1 was admitted to the Med/Surg Tele floor on 11/7/24 at 1430 hours, from the PACU and discharged on 11/12/24.

1. Review of the hospital's P&P tilted Care of the Adult Patient with Diabetes or Dysglycemia (Glucose Abnormalities) dated July 2024 showed patients with diabetes or dysglycemia will receive safe, effective care that includes as assessment and a care plan for proactive glucose management to promote optimal self-care after discharge. Hyperglycemia is defined as the blood glucose greater than 180 mg/dL. Insulin therapy is defined as insulin is the preferred treatment for glycemic control in the hospital setting. Patients with diabetes should have a diagnosis clearly identified in the medical record. All patients with Type 1 Diabetes must have basal and correctional insulin with the addition of nutritional insulin if patient is eating. If a patient has persistent hyperglycemia and no insulin orders are present or patient has correction scale insulin only, notify the physician. Documentation showed to document medications, treatment, care plan in the electronic medical record.

Review of the Preanesthesia Evaluation dated 11/7/24 at 0917 hours, showed Patient 1 had a medical history of Type 2 Diabetes.

During the concurrent interview to the Nurse Manager, the Nurse Manager was asked for the document of the patient's medical history. The Nurse Manager provided documents that the hospital received from the surgeon's clinic which showed Patient 1 visited the physician's office on 10/21/24 at 1540 hours. The document showed Patient 1 had a medical history of pancreatic insufficiency, Type 1 DM, and Type 2 DM uncontrolled.

Review of the Medication Documentation Review Audit showed on 11/7/24 at 0748 hours, the pre-operating RN reviewed Patient 1's home medications which included insulin glargine (Lantus, a long-acting insulin used to improve and maintain blood sugar level), 24 units to be injected under the skin every morning.

Review of the Hospitalist Progress Note dated 11/9/24 at 1456 hours, showed the Lab Results section showing Patient 1's blood glucose level was 306 mg/dL on 11/8/24 at 0516 hours. The "Scheduled Meds:" section showed insulin lispro (a fast-acting insulin used to lower the blood sugar level), 0-6 units subcutaneous four times daily, AC and HS.

Review of the Hospitalist Progress Note dated 11/10/24 at 1452 hours, showed the Lab Results section showing Patient 1's blood glucose level was 457 mg/dL on 11/10/24 at 1413 hours. The Assessment section showed Patient 1 had insulin dependent diabetes.

Review of the POCT Glucose showed Patient 1's blood glucose level was greater than 180 mg/dL as follows:

- On 11/10/24 at 1553 hours, Patient 1's blood glucose level was 417 mg/dL.
- On 11/10/24 at 2016 hours, the patient's blood glucose level was 390 mg/dL.
- On 11/11/24 at 0617 hours, the patient's blood glucose level was 358 mg/dL
- On 11/11/24 at 1220 hours, the patient's blood glucose level was 371 mg/dL.
- On 11/11/24 at 1637 hours, the patient's blood glucose level was 242 mg/dL.
- On 11/11/24 at 1917 hours, the patient's blood glucose level was 247 mg/dL
- On 11/11/24 at 2017 hours, the patient's blood glucose level was 234 mg/dL.
- On 11/12/24 at 0736 hours, the patient's blood glucose level was 267 mg/dL.

Review of the Plan of Care from 11/7/24 to 11/12/24 showed there was no documented evidence for the plan of care for diabetes or dysglycemia.

Review of the meal ' s intake document from 11/9/24 to 11/12/24, showed the patient was on a regular diet.

When asked, the Nurse Manager stated she was not able to locate documented evidence the RN notified or communicated with the providers regarding to Patient 1's abnormal blood glucose level as of 306 on 11/8/24 at 0516 hours.

2. Review of the hospital's P&P titled Nutrition Screening dated August 2022 showed the nursing will screen all patients within 24 hours of admission using the predetermined nutrition screening tool during the completion of the initial patient admission documentation. For adult patients, the pre-determined nutritional criteria include to use a Nutritional Risk Screening Tool 2002 (NRS-2002).

Review of the hospital's Nursing Malnutrition Risk Screen showed this helps to determine patients at nutritional risk to be prioritized for nutrition assessment. A score of 3 or signifies patient is at risk for malnutrition. The Malnutrition Risk Screen include the category of severity of disease. The Severity of Disease Reference section show "Mild Score 1" indicates the patient had chronic disease, admitted to the hospital due to complication. The example of the chronic disease is diabetes.

On 12/17/24 at 1327 hours, an interview and concurrent review of Patient 1's medical record was conducted with RN 1. RN 1 stated there was no documented evidence of a nutrition screening was completed within 24 hours of admission for Patient 1.

3. Review of the hospital's P&P tilted Pain Management dated November 2024 showed the following:

* Patients have the right to pain management

* Pain is assessed using approved, evidence- based validate scales appropriate for the patient's medical condition.

* Patients admitted to an inpatient care setting shall receive an initial screen at the time of admission to identify the presence pain. The information that may be obtained during this assessment includes, but is not limited to the intensity of pain, the location and nature of pain, the patient's tolerance to pain and acceptable of pain (pain goal); the patient history of analgesic use or abuse; and the patient respiratory risk factor.

* The patient will be assessed using the appropriate pain assessment tools a minimum of twice on both the day and evening shift and at least once during the night shift and PRN in the acute care area.

* In general, inpatient shall receive treatment for any active pain issue when intensity exceeds their acceptable level. Treatment is to be provided in a timely manner.

* If a treatment intervention for pain is provided, the response to that intervention should be assessed to include progress toward pain goal and side effects. The patient will be reassessed when drug approximately reaches peak effect as follows: after at least 30 minutes for IV administration (if the ordered frequency is less than 30 minutes, RN will perform reassessment prior to giving the next dose)

* Numerical Pain Rating Tools (NRS) is a pain scale, using numbers from 0-10 in which each number refers to a different pain level such that "0" represents "No Pain" to a rating of "10" which represents "the worst possible pain."

On 12/17/24 at 1348 hours, an interview and concurrent review of Patient 1's medical record was conducted with RN 1.

Review of the initial pain assessment documented on 11/7/24 at 1215 hours, showed at the preoperative unit, Patient 1's preferred pain scale was the numeric pain scale. The patient's acceptable comfort level was "3." The assessment did not include the intensity of pain, the location and nature of pain, the patient history of analgesic use of abuse, and the patient respiratory risk factors.

Further review of Patient 1's medical record showed Patient 1 admitted to med/surg unit on 11/7/24 at 1430 hours after the surgery. There was no documented evidence the med/surg unit admitting RN performed an initial pain assessment for Patient 1.

Review of the nursing notes, Medication Administration Report, Flowsheet History showed the pain management was not implemented for Patient 1 as follows:

* Review of the physician's order showed to administer hydromorphone (a pain medication) 1 mg every three hours as needed for moderate pain and severe pain to be started on 11/8/24 at 0647 hours and ended on 11/9/24 at 1549 hours.

The MAR showed hydromorphone 1 mg was administered to the patient on 11/8/24 at 1135, 1437, and 1737 hours; and 11/9/24 at 0425, 0836, 1212, and 1514 hours.

* Review of the physician's order showed to administer hydromorphone 2 mg every four hours as needed for moderate pain and severe pain to be started on 11/9/24 at 1551 hours and ended on 11/10/24 at 1542 hours.

The MAR showed hydromorphone 2 mg was administered to the patient on 11/9/24 at 2008 hours and 11/10/24 at 0506 hours.

On 12/17/24 at 1348 hours, RN 1 reviewed Patient 1's medical record and confirmed there was no documented evidence the nursing staff completed the initial pain assessment and conducted the pain reassessment after administered the above medications to the patient.