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Based on record review and interview, the facility failed to ensure that for one of one patients (Patient #1) admitted to the hospital with a diagnosis of Type I Diabetes, complete information was documented in her medical record regarding her treatment for Type I Diabetes.

Findings included:

Record review of her medical record on 04/18/2017 revealed but was not limited to the following: Patient #1 was admitted to the facility on 01/28/2017 for the treatment of depression with recent suicidal ideation. The patient stated that she was a Type 1 diabetic since age 4/5 years. The patient stated she takes Lantus insulin twice daily and Novolog sliding scale plus carbohydrate (carb) count with meals currently.

Record review of Patient #1's Physician's Orders, dated 01/28/017 at 0900 AM revealed physician ordered "please have her write down her Novolog sliding scale carb count insulin with each meal continue to follow her sliding scale and carb count doses with each meal.

Record review of Patient #1's Physician's Orders, dated 01/ ?/ 2017, no time noted, revealed

1. Novolog Sliding Scale with Meals to include:
Glucose less than 150 - No Novolog
150-200 1 unit Novolog
201- 250 2 units
251 - 300 3 units
301- 350 4 units
351 - 400 5 units

2. Carb count with meals
Breakfast Total Carb count divided by 6 = 6 units of Novalog
Lunch and Dinner Total Carb count divided by 10 = 6 units of Novalog
3. Dietary Instructions for "Healthy Eating" Type I Diabetes

This order was noted by a registered nurse on 01/29/017 at 1500 PM.

Record review of Patient #1's Medication Administration Record (MARS) for 01/29/2017 to 01/30/2017 did not reveal documentation of of Patient#1's carb count during the time she was an inpatient at the facility.

Record review of Patient#1's Medication Administration Record for Diabetic Sliding Scale revealed a glucose on 01/28/2017 upon admission of 289. On 01/28/2017 glucose was documented as 387 at 0730 AM, 289 at 11:30 AM, 289 at 4:00 PM. She refused glucose testing at bedtime on 01/28/2017. On 01/29/2017 glucose was documented as 347 at 0730 AM, 161 at 11:30 AM, 210 at 4:00 PM, and 410 at bedtime. On 01/30/2017 glucose was documented as 276 at 0730 AM and at 444 at 11:30 AM. Patient was discharged after this documentation. The Normal Glucose Range was listed as: 70-110 mg/dl.

Interview on 04/18/2017 at 2:40 PM with facility Licensed Vocational Nurse (LVN) #1 revealed but was not limited to the following:

LVN #1 stated she has worked at the facility for almost 11 years. She stated she was the LVN documenting the MARS of Patient #1 on 01/30/2017. She confirmed that she used the carbohydrate count the patient verbally related to her to determine how many units of Novolog to give the patient. She stated there would be no way for facility nursing staff to determine how many carbs are in the food that is eaten by the patients so she would depend on the information provided by the patient. She also confirmed there was no place on the MARS to document the information provided by the patient.