HospitalInspections.org

The Condition of Participation: Emergency Services was out of compliance.

Findings included:

Based on record review and interview, the Hospital failed to ensure one Patient (#3) out of a sample of ten patients received a Point of Care Test (POCT) for glucose (a fingerstick test done at the bedside to assess blood glucose levels) as ordered by the Physician. Patient #3 subsequently suffered hypoglycemia (low blood glucose) requiring Critical Response Team (CRT) activation, intravenous (IV) glucose and transfer to a higher level of care.

Cross reference:
482.55(a) Standard: Organization and Direction (A1101)

Based on record review and interview, the Hospital failed to ensure 1 Patient (#3) out of a sample of ten patients received a Point of Care Test (POCT) for glucose (a fingerstick test done at the bedside to assess blood glucose levels) as ordered by the Physician. Patient #3 subsequently suffered hypoglycemia (low blood glucose) requiring Critical Response Team (CRT) activation, intravenous (IV) glucose and transfer to a higher level of care.

Patient #3 was brought in by ambulance to the Emergency Department (ED) on 1/14/24 for evaluation of diarrhea, vomiting and hypoglycemia (low blood glucose levels). Patient #3's past medical history included metastatic cancer and anxiety.

Patient #3's medical record indicated on 1/15/24 the Physician ordered POCT glucose testing every 4 hours scheduled to begin on 1/15/24 at 4:00 P.M. Review of Patient #3's POCT glucose results indicated a level of less than 20 (normal range is between 70-100) on 1/15/24 at 9:07 P.M. (more than 5 hours after the POCT glucose test was ordered to begin).

Review of Registered Nurse (RN) #1's ED Rapid Assessment Nursing Note dated 1/15/24 at 10:25 P.M. indicated Patient #3's 8:00 P.M. POCT glucose check was completed at 9:00 P.M. and resulted in a glucose level of less than 20, the hospitalist was paged, a CRT was called, and the Patient received an ampule of Dextrose (D50W) 50% (used to treat low blood sugar) IV due to Patient #3's inability to swallow. Patient #3's blood glucose was rechecked at 9:24 P.M., after receiving the D50W and was 48 and Patient #3 subsequently received an additional ampule of D50 IV as well as a bolus (a single dose given all at once) of Dextrose 10% (D10) in normal saline (NS) IV. Patient #3's blood glucose level increased to 264 after receiving the IV Dextrose and the Patient was ultimately transferred to the Intensive Care Unit (ICU).

Review of Internal Medicine CRT Note dated 1/15/24 at 10:15 P.M. indicated the Physician responded to a CRT called for Patient #3 and that the Patient was unresponsive with hypoglycemia. The Note indicated Patient #3 was minimally responsive on presentation and their blood glucose was noted to be 20. D50W ampule was given x 2 followed by D10W bolus with resultant improvement to blood glucose of 256. The Note further indicated there was no motor or verbal response on command and the Patient was not withdrawing from pain and that given Patient #3's history of brain metastasis concern for hemorrhagic stroke, seizures and hypoglycemic encephalopathy was present. The Patient was ultimately transferred to the ICU for further care.

Review of Internal Medicine Resident Intensive Care Unit (ICU) History and Physical Exam Note dated 1/15/24 at 10:15 P.M. indicated that a CRT was called for Patient #3 as the Patient was unresponsive with blood sugars less than 20 and his/her gaze deviated to the left. Patient #3 was given amp of D50 with blood sugar increasing from less than 20 to 40s and given a second amp of D50 with blood sugar increasing to approximate 250s thereafter, however the Patient's mentation did not improve despite the improved blood sugar. Patient #3 was ultimately transferred to the ICU for Ceribell monitoring (monitoring for seizure activity) and frequent glucose checks.

During an interview on 4/4/24 at 10:19 A.M., RN #2 said she was Patient #3's nurse working during the day on 1/15/24. RN #2 said POCT glucose test frequency is based on physician orders and that either a nurse or an ED tech can obtain the POCT glucose tests and document the results in the electronic health record (EHR). RN#2 said she remembered Patient #3 and that on this day there was confusion all day regarding if the Patient was going to be changed to Comfort Measures Only (CMO) or hospice care and that the Physician was changing orders frequently throughout the shift. RN#2 said throughout her shift, Patient #3 was not answering much and was not eating or drinking. RN#2 said the Physician did place orders for POCT glucose checks every 4 hours to start in the afternoon or early evening, but around the same time, there were also labs drawn for Patient #3 and she did not obtain the 4:00 P.M. POCT glucose check as ordered. RN #2 said labs do not supersede POCT glucose tests and acknowledged this POCT was not done as ordered. RN #2 said several weeks after Patient #3's hypoglycemic event occurred, the ED Director asked her about what happened and why the POCT glucose test was not completed, and she explained that labs had been drawn around the same time. RN #2 said she was unaware of any re-education done with her or ED staff after the event.

During an interview on 4/3/24 at 3:16 P.M. RN #1 said there is generally a 1-hour window before and after an order is scheduled to complete the order. RN #1 said she remembered Patient #3 and said the Patient had been boarding (admitted to the hospital but waiting bed placement) in the ED for about 24 hours and that Patient #3 was admitted to the Hospital for gastrointestinal symptoms and low blood sugars and the Patient had cancer that had spread. RN #1 said she came on to her shift at 7:00 P.M. on 1/15/24 and said it was difficult to assess Patient #3's mental status due to brain cancer. RN #1 said she noted Patient #3 was due for a blood sugar test at 8:00 P.M. and when she checked the Patient's blood sugar sometime around 9:00 P.M., the result was less than 20 and RN #1 initiated a CRT and a whole team responded. RN#1 said it appeared some of Patient #3's orders had been missed that day, including the afternoon POCT glucose test, and she spoke with her manager about it after the event. RN #1 said Patient #3 received IV Dextrose to treat hypoglycemia, had a computerized tomography (CT) scan (medical imaging used to obtain detailed imaging), Ceribell monitoring and that ultimately Patient #3 transferred to the ICU. RN #1 said it was hard to say if Patient #3 would have gone to the ICU without the hypoglycemic event due to the Patient's poor mental status. RN #1 said she followed up with the ED Director sometime after the event and her understanding was that Patient #3 had labs drawn around 3:00 P.M. that day, so the day nurse did not obtain the POCT glucose test as ordered. RN #1 said she was unaware of any education or follow up done related to this event, but said she knew the ED Director had talked to the nurse involved to determine why the test wasn't completed.

During an interview on 4/4/24 at 11:14 A.M., the ED Director said Patient #3 had orders for blood sugar checks every 4 hours and that the Patient had a difficult neuro status at baseline. The ED Director said he asked RN #2 about the missed blood glucose test and was told that labs had been drawn sometime around the time the POCT glucose test was ordered, so she did not obtain the POCT glucose test as ordered. The ED director said the orders were separate, meaning Patient #3 had orders for specific lab tests, as well as orders for POCT glucose tests. The ED Director said he also asked RN #2 about handoff report to RN #1 and RN #2 was unsure if she had communicated when Patient #3 would be due for the next POCT glucose test. The ED Director said RN #1 recognized Patient #3's order for POCT glucose test every 4 hours sometime after it was due and when Patient #3 was tested, their blood sugar was low. The ED Director said there was big gap in shift-to-shift communication and both nurses acknowledged this and said workload was also a contributing factor. The ED Director said no widespread education or follow up was done after this event, and that RN #1 and RN #2 both demonstrated knowledge of what occurred, recognized issues related to the event and RN #2 acknowledged the POCT glucose test was not completed as ordered.

The Hospital failed to ensure POCT blood glucose testing was completed as ordered for Patient #3 while receiving insulin, Patient #3 was discovered to be hypoglycemic and was transferred to the ICU for monitoring and care.