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Based on observation, record review, and interview, the facility failed to provide care in a safe setting. This deficient practice was evidenced by failure to document glucometer quality controls according to facility policy.

Findings:

Review of the facility's policy NSG-26, last revised date of 07/01/2022, titled "Glucometer Method for Obtaining CBGs" revealed in part: "Confirm System Performance/Control Test: A control test confirms that the system is functioning properly. Control tests are to be performed every 24 hours of patient use and anytime there is a question about the blood glucose test results."

Observation of the Glucometer Quality Control Log on 10/11/2023 at 10:10 a.m. revealed daily controls not completed for 09/23/2023, 09/24/2023, and 10/03/2023.

In an interview on 10/11/2023 at 10:13 a.m. S2QA verified the glucometer quality controls were not performed on 09/23/2023, 09/24/2023, and 10/03/2023.

Review of the order sets for 09/23/2023, 09/24/2023, and 10/03/2023 revealed 9 patients required finger stick blood glucose monitoring on 09/23/2023, 10 patients required finger stick blood glucose monitoring on 09/24/2023, and 5 patients required finger stick blood glucose monitoring on 10/03/2023.

In an interview on 10/11/2023 at 10: 15 a.m., S3QD verified there were no quality controls performed on 09/23/2023, 09/24/2023, and 10/03/2023. Furthermore, S3QD verified 9 patients required finger stick blood glucose monitoring on 09/23/2023, 10 patients required finger stick blood glucose monitoring on 09/24/2023, and 5 patients required finger stick blood glucose monitoring on 10/03/2023.

Based on record review and staff interview, the hospital failed to ensure History and Physical examinations were completed within 24 hours after admission to the hospital according to facility policy.
Findings:

Review of the Medical Staff Bylaws revealed in part the following: "Article XIII Initial Patient Screening Section 1: History and Physical: A. History and Physical. The Medical Staff shall implement policies and clinical processes designed to ensure that a complete history and physical (H&P) on each patient is written or dictated, transcribed and authenticated within twenty-four (24) hours of admission and not more than thirty (30) days prior to the admission. "

Review of the policy titled "Medical, History and Physical Examination," last revised 04/01/2021, revealed in part: "Inpatient admissions: A comprehensive medical history and physical examination (H&P) is conducted on each patient and is written or dictated and transcribed within twenty-four (24) hours of admission and no more than thirty (30) days prior to the admission."

Record review performed on 10/11/2023 of all admitted patients from 09/01/2023 to 10/11/2023 revealed the History & Physical examination for 35 of 99 admitted patients were not completed within 24 hours of admission.

In an interview on 10/11/2023 at 10:08 a.m., S2QA verified the History and Physical examinations for 35 of 99 patients admitted from 09/01/2023 to 10/11/2023 35 were not completed within 24 hours of admission.

In an interview on 10/11/2023 at 12:20 p.m., S1ADM verified the History and Physical examination for 35 of 99 patients admitted from 09/01/2023 to 10/11/2023 35 were not completed within 24 hours of admission.