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Based on review of records and interview with staff, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for Patient #1, as 3 of 3 documented low blood sugar levels were not monitored as ordered by the physician.

Findings were:

Review of the medical record of Patient #1 revealed that the patient has insulin dependent Diabetes Mellitus. While in the hospital, the physician signed an order for a sliding scale to better regulate blood sugar levels. The term "sliding scale" refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges. Sliding scale insulin regimens approximate daily insulin requirements. The physician order, written at admission, 1/13/14, outlined interventions to be taken should Patient #1's blood sugar level drop below 70 milligrams per deciliter (mg/dl). As part of the interventions, the order states that the patient's blood sugar level should be tested every 15 minutes after treatment until the level rises to 70 or greater. According toPatient #1's medical record, this was not done as ordered 3 times that blood sugar levels dropped below 70 mg/dl.

1. On 1/21/14, Patient #1's blood sugar level was 50 mg/dl at 4:26 pm. The nurse followed the physician order and treated the patient with dextrose (simple sugar), then tested the blood sugar level again 30 minutes later; it had returned to a normal reading of 123. This did not follow the physician order to monitor the level every 15 minutes until it returns to 70 or above.

2. On 1/21/14, at 11:32 am, Patient #1's blood sugar level was 53 mg/dl. The nurse ensured that the patient consumed a full lunch tray, and at 4:30 pm the blood sugar level was 159. This testing was done 5 hours later, not every 15 minutes until return to at least 70 as ordered by the physician.

3. On 1/22/14 at 4:38 pm, the patient's blood sugar level was 64mg/dl. The nurse documented that the patient was given 4 ounces of juice as ordered. The blood sugar level was checked again 40 minutes later, and it had returned to normal at 106 mg/dl. The level was not rechecked every 15 minutes until it returned to 70 or greater per physician order.

These findings were verified in an in-person interview during record review the afternoon of 4/1/14 with the Nurse Manager of the Units where Patient #1 was treated.