HospitalInspections.org

Based on record review and staff interview it was determined the registered nurse failed to identify and intervene a patient's need related to an elevated blood glucose level and change in condition for 1 (#1) of 10 sampled patients.

Findings include:

Patient #1 was admitted on 12/28/12 for orthopedic surgery. Review of the History and Physical dictated by the orthopedic surgeon revealed the patient had diabetes and end stage renal disease. The patient was on oral diabetes medications and peritoneal dialysis daily at home.

Review of laboratory result revealed a blood glucose of 443 (70-110) on 12/29/12 and 418 on 12/30/12. There was no documentation by nursing regarding the significantly elevated blood glucose. On 12/30/12 a nurse performed a bedside blood glucose test and found the blood glucose to be 315. Review of physician orders revealed an order for sliding scale insulin to be given according to the bedside glucose result.

Review of the Medication Administration Record (MAR) revealed the nurse failed to administer insulin in response to the elevated blood glucose. The patient should have received 7 units of insulin.

Review of the MAR revealed the 10:00 p.m. dose of oxycodone was held on 12/30/12 due to "sedation." This reflected a change in mental status. There was no evidence this was reported to the physician. The surgeon noted in his progress note on 12/31/12 at 8:40 a.m. that the patient was found to be "obtunded". He ordered the patient to be transferred to the Intensive Care Unit.

The nurse who cared for the patient on 12/31/12 in the morning was interviewed via phone call on 8/8/13 at approximately 10:12 a.m. She stated she had been given report the morning of 12/31/12 that the patient had been very lethargic during the night.

The Nursing Director of Emergency Department and Trauma was present during the record review on 8/8/13 and confirmed the findings