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Based on review of one of two medical records of patients with a low blood glucose level in the Emergency Department (ED) (Medical Record #1 and #4), staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that patient's presenting to the ED with abnormal blood glucose levels are properly stabilized.

Findings include:

A review of Medical Record #1 revealed the following:

Patient #1 (P1) was brought to the ED on 6/30/22 at 4:30 PM, for hyperglycemia (high blood glucose level). The point of care testing (POCT) for glucose at 5:07 PM was 400 mg/dL (milligrams/deciliter). P1 was given regular insulin 8 units subcutaneously at 5:38 PM. At 6:47 PM, the POCT glucose was 338 mg/dL. P1 was given a second dose of regular insulin 8 units subcutaneously at 7:12 PM as ordered by the ED physician. The second dose of 8 units regular insulin was given one hour and 34 minutes after the first dose. A repeat POCT glucose at 8:20 PM was performed and the result was 174 mg/dL. There was no further glucose testing done on P1. At 9:07 PM, the ED physician wrote a re-assessment note and prepared the discharge instructions. The RN (Registered Nurse) note at 9:45 PM stated that P1 was cleared for discharge but the RN did not document a final assessment of the patient's condition prior to discharge. P1 was discharged at 10:00 PM and was picked up by the social worker from his/her group home.

On 6/30/22 at 10:41 PM, P1 was back in the ED for low blood sugar (BS). A review of the BLS (basic life support) notes from the EMT (Emergency Medical Technician) stated that at 10:22 PM on 6/30/22, P1 was in the passenger seat of the car in the driveway of the group home. P1 was alert to person and place but confused to time and event. The facility staff told the EMT that P1 was just picked up from the hospital and when they pulled into the driveway of the group home, the patient was unresponsive and diaphoretic (profuse sweating), and speech was slurring. P1 told EMT that he/she had no food during the day and only had a sweet, iced tea. P1 was transported to the hospital and upon arrival to the hospital ED at 10:36 PM, P1 was alert and oriented x [times] 4.

The FS (fingerstick) indicated a blood sugar of 59 at 10:42 PM. The patient was triaged and was assigned an acuity level of three (3) which according to Staff (S)10, Nurse Manager, means that the patient was alert, oriented x 4. An RN note at 11:15 PM stated, "patient was given sandwich and beverage as requested. AO [awake, alert, oriented] x4 and conversing with staff." The note does not indicate which type of beverage was provided to P1 and the food was provided 33 minutes after a FS of 59. This was not in accordance with facility protocol. P1's blood sugar was not retested at 11:30 PM, in accordance with the Hypoglycemia Protocol. At 11:31 PM, the ED physician evaluated P1 and found P1 unresponsive, not breathing, and pulseless. CPR (Cardiopulmonary Resuscitation) was immediately initiated at 11:35 PM. P1 was found to have copious amounts of gastric secretions in the airway that delayed the intubation. ED staff performed BVM (bag valve mask) ventilations due to difficult intubation. They continued CPR and medications were given. The patient was pronounced dead at 12:55 AM on July 1, 2022.

Upon interview on 6/13/23 at 11:35 AM, S5, Director of Nursing ED, stated that for a hyperglycemic patient they follow the Insulin Management protocol, also known as Diabetic Order set. Per S5, the ED physician will be notified immediately and will order laboratory tests and then insulin. The insulin dose will be physician driven, and based on what kind of insulin was ordered, they will repeat the FS (fingerstick) which is usually every hour. Upon review of the protocol, it did not contain a protocol for management of hyperglycemia in the Emergency Department (ED).

Upon interview on 6/14/2023 at 11:50 AM, S10, stated that a final assessment prior to patient's discharge has to be performed and documented in the electronic medical record (EMR). S10 also stated that they will recheck the blood sugar depending on what kind of insulin was given to the patient. In the case of regular insulin, it peaks in two hours. S10 stated that based on a blood sugar of 174 mg/dL, it wasn't necessary to repeat the FS prior to P1's discharge. When asked about giving snacks, S10 stated they only give snacks if the patient has low blood sugar.

A review of the facility policy titled, "Discharging the Emergency Department Patient," effective date 6/10/2022, states, "... 10.0 The primary nurse will document a final assessment of the patient's condition upon discharge in the electronic medical record. ..."

The facility Hypoglycemia Protocol, effective 1/24/22, was reviewed and indicated the following: If patient is conscious/able to swallow/enteral feedings: "... BG [blood glucose] < [less than] 70 mg/dL - Administer 15 g of CHO [carbohydrate] [carbon, hydrogen,oxygen]: 1st : 4 oz. [ounces] apple/cranberry juice or 2nd: 15 of oral glucose gel and a meal/snack within 30 mins. [minutes] ... re-test BG in 15 mins ... reassess and repeat BG checks every 15 minutes until BG > [greater than] 70 mg/dL ..."