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Based on observation, interview, and document review, the hospital failed to ensure a patient (P1) had their blood glucose level obtained, and prescribed dose of insulin administered prior to eating breakfast.

Findings include:

P1's medical record note dated 3/19/20, indicated P1 was diagnosed with diabetes mellitus Type II without complications, and dementia. The note indicated it was last reviewed by registered nurse (RN)-A on 1/20/20.

P1's medical record medication list dated 1/19/20, indicated orders for glargine insulin, with instructions to injected 20 units subcutaneously in the morning before breakfast.

On 1/19/20, at 11:39 p.m. P1 was admitted to the hospital emergency department with complaints of abnormal outbursts, and assaulting staff in the group home he lived. While in route to the hospital, P1 continued to assault ambulance personnel. Due to continued outbursts on 1/19/20, medical doctor (MD)-A prescribed intravenous Zyprexa for P1. P1 was allowed to sleep through the night, and her care was transferred to MD-B on 1/20/20, at 7:26 a.m.

On 1/20/20, at 7:20 a.m. RN-A completed a shift hand-off to RN-B. On 1/20/20, at 7:32 a.m. RN-B documented P1 received a breakfast tray.

During an interview on 9/23/20, at 12:02 p.m. a community social worker (SW)-A stated she was informed by RN-B on 1/20/20, at 11:15 a.m. that P1 was not administered any of her morning medications. SW-A inquired if P1 had her blood glucose obtained, and if had her insulin. RN-B indicated P1 had not. On 1/20/20, at 11:25 a.m. RN-B completed a glucometer test that indicated P1 had a blood sugar level of 215.

During an interview on 9/24/20, at 10:37 p.m. RN-B was interviewed and stated when a patient was admitted to the emergency department, diagnoses and medication lists were reviewed. RN-B reviewed the electronic medical record, and stated insulin was on the medication administration record (MAR). RN-B also confirmed no insulin was given. RN-B stated if the physician does not enter an order for a medication, she would not be looking for it. RN-B further stated the overnight physician would be responsible to order morning medications, and the day shift would be responsible for giving them.

During an interview on 9/24/20, at 1:44 a.m. Admin-Operations (AO)-A stated depending on the group home, they may or may not send a current medication list. When obtained, the provider would review it and the provider was responsible for putting in a medication order. After review of the medical record, AO-A stated the order for insulin was likely forgotten.

During an interview on 9/24/20, at 10:48 a.m. MD-C reviewed P1's medial record and MAR and stated no insulin had been ordered by the overnight physician.

A policy was requested and not provided.