HospitalInspections.org

Based on record review and staff interview, it was determined that the facility failed to ensure that the Registered Nurse provide sufficient supervision to ensure that the patient's nursing care needs related to monitoring of blood glucose levels were met for 1 (#1) of 3 sampled patients. This practice may result in failure to achieve patient care goals.


Findings include:


Review of the medical record of patient #1 revealed that he was admitted on 10/21/10. Included in the admitting orders was an order for accucheck monitoring of blood glucose before meals and at night. Review of nursing documentation of the blood glucose monitoring revealed that the monitoring was not performed on 10/21/10 prior to the evening meal and on 10/22/10 prior to the evening meal. The Clinical Transformatics leader was interviewed on 11/3/10 during the review of the medical record. She confirmed that there was no evidence that that the nursing staff had performed the accucheck monitoring as ordered.

Based on record review and staff interview, it was determined that the nursing staff failed to administer pain medication as ordered by the physician for 1 (#1) of 3 sampled patients. This practice does not ensure the goal of pain management is achieved for the patient.


Findings include:



Patient #1 was admitted to the facility on 10/21/10. Included in the physician orders was an order for MS Contin 30 milligrams orally every 8 hours as needed for pain. Documentation of the patient's pain assessment and administration of the ordered pain medication were reviewed. The patient reported pain at the level of 6 on a 0 - 10 scale at 8:00 p.m. on 10/21/10. No medication was administered at that time and there was no documentation as to why the medication was not administered. The next pain assessment was performed at 8:55 p.m. The pain level had excalated to 8 on the scale. The ordered medication was administered at that time. The patient reported pain at the level of 8 on the pain scale at 8:00 a.m. on 10/22/10. The patient had received the MS contin at 5:27 a.m. Therefore, it was too soon to administer the ordered medication. However, there was no evidence that the nursing staff notified the physician of the failure of the ordered pain medication to control the patient's pain. There was no evidence of another pain assessment until 3:35 p.m. The pain level was reported at 10, the most severe pain. The MS Contin was then administered. There is no evidence that the patient's pain had been relieved between 8:00 a. m. and 3:35 p.m. on 10/22/10. The patient reported pain at 5 on the scale at midnight on 10/23/10. There was no evidence that pain medication had been administered. There was no pain assessment again until 3:00 a.m. The patient reported the pain at a level of 8. The MS contin was then administered. The Clinical Transformatics leader was present during the record review on 11/3/10 and confirmed the above findings.