HospitalInspections.org

Based on record review and interview, the hosptial failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failure to ensure notification of the physician and actions taken to address a patient's lab result (serum blood glucose) reported as critically low (less than 30 mg/dL) was documented in the patient's record for 1 (#6) of 11 (#1-#11) total sampled patient records reviewed;
2) failure to ensure ordered capillary blood glucose readings were documented in the patient record for 6 (#1, #3, #4, #5, #9, #10) of 6 (#1, #3, #4, #5, #9, #10) Diabetic patients' records reviewed from 11 (#1-#11) total sampled patient records reviewed; and
3) failure to ensure oral nutritional supplement intake or refusal, ordered for a patient with poor intake and an identified problem of malnutrition, was documented in the patient's record for 1 (#6) of 1 patients reviewed for nutritional supplementation out of a 11 total sampled patient records reviewed.

Findings:

1) Failure to ensure notification of the physician and actions taken to address a patient's lab result (serum blood glucose) reported as critically low (less than 30 mg/dL) was documented in the patient's record.

Review of Patient #6's medical record revealed an admission date of 7/3/18 with admission diagnoses of Depression and Bipolar Disorder.

Review of Patient #6's nurses' notes entries revealed an entry dated 7/10/18 at 3:20 p.m.: Critical lab value glucose less than 30 (mg/dL) asymptomatic, Blood glucose check to follow. Further review of the patient's entire electronic medical record revealed no documentation of actions taken to address the critical low blood glucose value and no documentation of physician notification of the critical lab value results.

In an interview on 8/7/18 at 1:40 p.m. with S3RiskMgr, she confirmed, after review of the patient's entire electronic medical record, that there was no documented evidence of any actions taken to address the critical low blood glucose value and no documentation of physician notification of the critical lab value results.

2) Failure to ensure ordered capillary blood glucose results were documented in the patient record.

Patient #1
Review of Patient #1's medical record revealed she had been admitted on 7/10/18 with diagnoses which included Severe Depression and Type 2 Diabetes.

Review of Patient #1's physician's orders revealed an order dated 7/10/18 to check blood glucoses before meals and at bedtime.

Review of Patient #1's medical record revealed only one blood glucose was documented on 7/14/18 at 4:47 a.m. Further review revealed no documentation as to why the blood glucoses had not been obtained/documented.

Patient #3
Review of Patient #3's medical record reveled he had been admitted on 7/8/18 with diagnoses including Schizophrenia and chronic Diabetes.

Review of Patient #3's physician's orders revealed orders dated 7/9/18 for blood glucose readings at 7:00 a.m. ; 7/10/18 at 7:00 p.m.;7/11/18 at 7:57 a.m., 12:00 p.m. and 7:00 p.m.

Review of Patient #3's electronic medical record revealed no capillary glucose results were recorded at those times.


Patient #4
Review of Patient #4's medical record revealed he had been admitted on 7/12/18 with diagnoses which included severe Depression and Type II Diabetes.

Review of Patient #4's physician's orders revealed an order dated 7/12/18 at 10:00 p.m. for blood glucoses 4 times daily before meals and at bedtime.

Review of Patient #4's blood glucose log revealed no documentation of blood glucoses being obtained or why they were not performed except on 7/13/18 at 9:00 p.m. The patient was discharged on 7/14/18.

Patient #5
Review of Patient #5's medical record revealed he had been admitted on 7/8/18 with diagnoses including Bipolar Disorder and Depression. He was discharged on 7/19/18.

Review of Patient #5's physician's orders revealed an order dated 7/10/18 at 7:36 p.m. for blood glucoses before meals and at bedtime.

Review of Patient #5's blood glucose log revealed the only blood glucose documented was on 7/11/18 at 7:27 p.m. The order was discontinued on 7/15/18 at 9:47 p.m.

Patient #9 (current patient)
Review of Patient #9's medical record revealed an admission date of 8/7/18 with diagnoses including Schizophrenia and Type II Diabetes. Further review revealed the patient had long-term use of Levermir insulin and accuchecks daily prior to hospitalization.

Review of Patient #9's physician's orders revealed an order dated 8/7/18 at 9:31 a.m. for blood glucoses 4 times daily, before meals and at bedtime.

Further review of Patient #9's medical record revealed no documented capillary blood glucose testing results.


Patient #10 (current patient)
Review of Patient #10's medical record revealed an admission date of 8/5/18 with a co-morbid diagnosis of Type II Diabetes. Further review revealed the patient's Diabetes was managed with Metformin (oral Diabetic medication) prior to hospitalization.

Review of Review of Patient #10's physician's orders revealed an order dated 8/5/18 at 4:53 p.m. for blood glucoses 4 times daily, before meals and at bedtime.

Further review of Patient #10's medical record on 8/7/18 revealed no documented capillary blood glucose testing results were documented after 8/5/18 at 4:53 p.m.

In an interview on 8/7/18 at 1:10 p.m. with S2DON, she verified the above referenced ordered capillary blood glucose results were not documented in the patients' electronic medical records. S2DON reported agency nurses used a hand held device to obtain capillary blood glucoses that did not automatically upload to the hospital's electronic medical records.

3) Failure to ensure oral nutritional supplement, intake or refusal, ordered for a patient with poor intake and an identified problem of malnutrition, was documented in the patient's record.

Review of Patient #6's medical record revealed an admission date of 7/3/18. Further review revealed the following Intake Note, in part, dated 7/3/18: Depression since death of his daughter, patient not eating, talking, or wanting to get up.

Review of Patient #6's nurses' notes revealed the following entries, in part:
7/5/18 3:45 p.m.: Boost (oral nutritional supplement) ordered TID (3 times/day).
7/6/18 12:00 p.m.: Patient notably somber refusing to eat or drink.
7/9/18 12:45 p.m.: Patient awake alert, poor appetite, consuming very little fluids. He is encouraged to eat and drink but refuses.
7/10/18 11:46 a.m.: Admits to feeling depressed and sad. Refusing to eat and drinking very little.

Review of Patient #6's treatment plan revealed the patient had been care planned for malnutrition as an identified problem.

In an interview on 8/7/18 at 12:51 p.m. with S2DON, she confirmed the patient's oral nutritional supplement intake or refusal had not been documented in the patient's electronic medical record after review of the entire record.

Based on record review and interviews, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented in accordance with hospital policy and acceptable standards of practice. This deficient practice was evidenced by failure of the hospital to ensure staff cleaned and disinfected the glucometer after performing a capillary blood glucose as per manufacturer's suggested disinfection method (used as the hospital's disinfection policy).

Findings:

Review of the manufacturer's suggested disinfection method documentation, presented as the hospital's current accepted method of glucometer disinfection by S3RiskMgr, revealed the following, in part: Approved product: PDI Sanicloth with bleach. When to clean: 3. Clean and disinfect following use on each patient. Note: Disinfection is a process that destroys pathogens, such as viruses and other microorganisms on the meter surfaces.

In an interview 8/7/18 at 9:45 a.m. with S4MHT, she reported she had cleaned the unit's glucometer (used for capillary blood glucose readings on patients) with alcohol wipes between patients when she had obtained the patients' capillary blood glucose readings on 8/7/18.

In an interview 8/7/18 at 3:00 p.m. with S3RiskMgr, she reported she thought the manufacturer's suggested method of disinfection was to use alcohol to disinfect the meter between patients because other products may have damaged the meter.

Based on record review and interview, the hospital failed to ensure each patient had a comprehensive treatment plan. This deficient practice is evidenced by failing to update the treatment plan for patients placed on contact isolation precautions for a diagnosis of scabies for 2 (#8, #11) of 2 patients reviewed for a diagnosis of scabies from a total patient sample of 11 (#1- #11).

Findings:

Patient #8
Review of Patient #8's medical record revealed an admission date of 6/16/18.

Further review of Patient #8's medical record revealed the following Nurse Practitioner's note, in part, dated 6/19/18 at 4:46 p.m.: Patient seen and examined. Patient currently on isolation. Visible red bumps on arms bilaterally and chest. Reddened rash bumps noted to face and body. Medicated shower completed and cream applied.

Review of Patient #8's treatment plan revealed no documented evidence of an update after the patient's diagnosis and treatment for scabies and placement on contact isolation precautions.

Patient #11
Review of Patient #11's medical record revealed an admission date of 6/19/18.

Further review of Patient #11's medical record revealed the following Nurse Practitioner's note, in part, dated 6/23/18 at 9:15 a.m.: Nurse reports concern over rash and frequent bouts of pruritus, reports worsening. Skin: rash noted. Erythematous circular rashes of pustular eruptions in a linear pattern. Assessment/Plan: scabies/possible scabies exposure. Treat with Elimite (head lice and scabies treatment medication). Contact isolation continued.

Review of Patient #11's treatment plan revealed no documented evidence of an update after the patient's diagnosis and treatment for scabies and placement on contact isolation precautions.

In an interview on 8/8/18 at 10:00 a.m. with S3RiskMgr, she verified contact isolation precautions and diagnosis and treatment for scabies should have been addressed on the patients' treatment plans. S3RiskMgr confirmed the above referenced patients' plans had not been updated and verified the plans should have been updated.