HospitalInspections.org

30984




31048

Based on interview and record review the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to notify the Medical Doctor (MD) of a capillary blood glucose level which was out of ordered range, as directed, on patients' MD orders for 2 (#F1, #F2) of 6 (#F1- #F6) Diabetic patients reviewed.
2) Failed to ensure the LPN (Licensed Practical Nurse) administered 6 units of insulin for a capillary blood glucose of 277 mg/dl (milligrams/deciliter) as directed by MD's sliding scale orders for 1 (#F1) of 6 (#F1-#F6) Diabetic patients reviewed.
Findings:

1) The RN failed to notify the Medical Doctor (MD) of a capillary blood glucose level which was out of ordered range, as directed, on patients' MD orders.

Patient #F1
Review of Patient #F1's medical record revealed an admission date of 4/30/14 (formal voluntary admission) and diagnoses including the following: Schizophrenia, Diabetes Mellitus and Hypertension.
Review of Patient #F1's MD orders revealed the following order:
5/1/14 9:00 a.m.: Accuchecks (capillary blood glucose) AC (before meals) and HS (hour of sleep) with my sliding scale regular insulin

Review of Patient #F1's Medication Administration Record revealed the following Sliding Scale Insulin orders:
Blood Sugar:
61-150 = No insulin
151- 200 = 2 units
201 - 250 = 4 units
251 - 300 = 6 units
301- 350 = 8 units
351 - 400 = 10 units
Blood sugar > (greater than) 400 = 12 units, re-check blood sugar in 2 hours and call MD.

Review of Patient #F1's Diabetic Flow sheet (documenting capillary blood sugar readings) revealed the following, in part:
Note: Use comment section to document physician notification or additional pertinent information.

5/10/14, 11:30 a.m.: 452: coverage: 12 units at 12 N (noon); Comments: SF6RN notified; Documented by SF5LPN

Review of Patient #F1's nurses daily shift assessment notes for 5/10/14 revealed no documentation of the patient's elevated capillary blood glucose (CBG) levels. Further review revealed no notification of the patient's MD of the elevated CBG levels.

In an interview on 5/12/14 at 2:20 p.m. with S2FDON he confirmed Patient #F1's MD should have been notified of the patient's elevated CBG result. S2FDON verified the patient's MD had not been notified after reveiwing Patient #F1's medical record.

Patient #F2
Review of the medical record for Patient #F2 revealed he was a 51 year old male admitted on 5/1/14 with diagnosis which included Bipolar I Depression severe with psychosis. Further review of the psychiatric evaluation revealed the physician documented the patient had "Hyperglycemia with DM (?)". (Diabetes Mellitus)

Review of a Physician's Order for Patient #F2 dated 5/2/14 at 7:50 a.m. revealed an order for accuchecks BID (twice per day) x 48 hours and call MD (Medical Doctor) if > or = 200 (greater than or equal to 200).

Review of the Medication Administration Record for Patient #F2 dated 5/3/14 at 4:30 p.m. revealed the patient had a blood glucose level of 243. Further review revealed no blood glucose was documented on 5/3/14 other than the one at 4:30 p.m. and no documentation was in the medical record that the physician was notified of the blood glucose of 243.

In an interview with SF2DON on 5/12/14 at 1:52 p.m., he verified the a.m. blood glucose had been completed only once on 5/2/14, not twice as ordered. SF2DON also verified there was no documentation of the physician being notified of Patient #2's blood glucose being 243 on 5/3/14 at 4:30 p.m.


2) Failing to ensure the LPN (Licensed Practical Nurse) administered 6 units of insulin for a capillary blood glucose of 277 mg/dl (milligrams/deciliter) as directed by MD's sliding scale orders.
Patient #F1
Review of Patient #F1's Medication Administration Record revealed the following Sliding Scale Insulin orders:
Blood Sugar:
251 - 300 = 6 units

Review of Patient #F1's Diabetic Flow sheet (documenting capillary blood sugar readings) revealed the following, in part:

5/10/14, 2:00 p.m.: 277 mg/dl: Coverage: none, recheck; Comments: blank; Documented by SF5LPN.


Review of Patient #F1's nurses daily shift assessment notes for 5/10/14 revealed no documentation of the patient's elevated capillary blood glucose (CBG) levels. Further review revealed no documentation of administration of 6 units of insulin as ordered for a CBG of 277 mg/dl.

In an interview on 5/12/14 at 2:20 pm with SF2DON he confirmed Patient #F1 should have received 6 units of insulin as directed per sliding scale insulin order for a CBG of 277 mg/dl. He verified the patient had not received 6 units of insulin after review of the patient's medical record.

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Based on interview and record review, the hospital failed to ensure the nursing staff developed, implemented and kept current a nursing care plan for each patient as evidenced by:
1) failing to initiate a nursing care plan for the diagnosis of Hyperglycemia for 1 (#F2) of 6 (#F1- #F6) patients sampled.
2) failing to include interventions for the problem of Diabetes for 1 (#F3) or 6 (#F1- #F6) patients sampled.
3) failing to ensure implementation of Diabetic Patient Care Plan interventions by failing to confirm 1800 calorie ADA (American Diabetic Association) diets were being administered as prescribed for 4 (#F1,#F4, #F5, #F6) of 6 (#F1-#F6) patients sampled .

1) Failing to initiate a nursing care plan for Hyperglycemia.

Review of the medical record for Patient #F2 revealed he was a 51 year old male admitted on 5/1/14 with diagnosis which included Bipolar I Depression severe with psychosis. Further review of the psychiatric evaluation revealed the physician documented the patient had " Hyperglycemia with DM (?)". (Diabetes Mellitus)

Review of the Master Treatment Plan for Patient #F2 revealed an Axis III diagnosis of Hyperglycemia. No care plans were located in the medical record for Hyperglycemia.

In an interview with SF2DON on 5/12/14 at 1:52 p.m., he verified the care plans for Patient #F2 did not include Hyperglycemia but should have.

2) Failing to include interventions for the problem of Diabetes.
Review of the medical record for Patient #F3 revealed she was admitted on 5/3/14 with diagnosis which included Schizoaffective disorder and Diabetes mellitus.

Review of the Interdisciplinary Plan of Care for Patient #F3 revealed a problem initiated for Diabetes. Further review revealed no interventions had been initiated for Diabetes.

In an interview with SF2DON on 5/12/14 at 1:52 p.m., he verified interventions for Patient #F3 were not initiated on the care plan for diabetes.

3) Failing to ensure implementation of Diabetic Patient Care Plan interventions by failing confirm 1800 calorie ADA (American Diabetic Association) diets were being administered as prescribed.

Patient #F1
Review of the medical record for Patient #F1 revealed he was admitted on 4/30/14 with diagnosis which included Schizophrenia and Diabetes mellitus.

Review of the admission order sheet for Patient #F1 dated 4/30/14 at 5:15 p.m. revealed an order for an 1800 calorie ADA diet.

Review of Patient #F1's care plan for Diabetes, initiated 5/3/14, revealed the following Approaches/Interventions, in part:
Nursing will administer diet as prescribed.

Review of the Dietary Intake and Output Sheets for Patient #F1revealed the following entries:
5/3/14- Morning Snack: Cookies; Evening Snack: Chips
5/4/14- Morning Snack: Cookies
5/5/14- Evening Snack: Cookies
5/6/14: Morning Snack: Chips
5/7/14: Morning Snack: Oreos; Evening Snack: Cookies and Chips
5/8/14: Morning Snack: Shortbread Cookies
5/9/14: Evening Snack: Cookies

In an interview on 5/12/14 at 12:21 p.m. with SF3Dietician said diabetic menus consisted of three meals, an a.m. snack (choices: SF (Sugar Free) Jello, SF pudding, Crystal Light and/or 3 graham cracker squares) and a bedtime snack ( 1/2 sandwich and/or skim milk ). She confirmed chips, cookies (Oreos, Shortbread) and Chex mix were not appropriate snacks for a 1800 calorie ADA diet.

In an interview with SF2DON on 5/12/14 at 1:50 p.m., he verified the Oreos, Shortbread Cookies and Chips Patient #F1 was being given were not allowed on an ADA diet. SF2DON said, after review of the Dietary Intake and Output Sheets, "So we're giving them the wrong diet and controlling their blood sugar with insulin."

Patient #F4
Review of the medical record for Patient #F4 revealed she was admitted on 5/3/14 with diagnosis which included Depressive Type Psychosis and Diabetes mellitus.

Review of the admission order sheet for Patient #F4 dated 5/3/14 at 11:01 a.m. revealed an order for an 1800 calorie ADA diet.

Review of Patient #F4's care plan for Diabetes, initiated 5/3/14, revealed the following Approaches/Interventions, in part:
Nursing will administer diet as prescribed.

Review of the Dietary Intake and Output Sheets for Patient #F4 revealed the following entries:
5/3/14- Evening Snack: Chips
5/4/14- Morning Snack: Cookies
5/5/14- Morning Snack: Chips; Evening Snack: Chips
5/6/14: Morning Snack: Chex Mix

In an interview with SF2DON on 5/12/14 at 1:53 p.m., he verified the Cookies, Chex mix and Chips Patient #F4 was being given were not allowed on an ADA diet.

Patient #F5
Review of the medical record for Patient #F5 revealed he was a 44 year old male admitted on 5/2/14 with diagnosis which included Schizoaffective Disorder and Diabetes Mellitus.

Review of the Physician's Admission Orders for Patient #F5 dated 5/2/14 at 8:20 p.m. revealed an order for an 1800 calorie ADA diet and a low Sodium Diet.

Review of Patient #F5's care plan for Diabetes revealed the following Approaches/Interventions, in part:
Nursing will administer diet as prescribed.

Review of the Dietary Intake and Output Sheets for Patient #F3 revealed the following entries:
5/2/14- Evening Snack: Chips
5/3/14- Morning Snack: Cookies; Evening Snack: Chips

In an interview on 5/12/14 at 3:30 p.m. with SF2DON, he verified chips and cookies were not part of a diabetic diet.

Patient #F6
Review of the medical record for Patient #F6 revealed she was admitted on 5/6/14 with diagnosis which included Depression and Diabetes Mellitus.

Review of the admission order sheet for Patient #F6 dated 5/6/14 at 7:00 p.m. revealed an order for an 1800 calorie ADA diet.

Review of Patient #F6's care plan for Diabetes, initiated 5/6/14, revealed the following Approaches/Interventions, in part:
Nursing will administer diet as prescribed.

Review of the Dietary Intake and Output Sheets for Patient #F6 revealed the following entries:
5/7/14- Evening Snack: Chips
5/8/14- Evening Snack: Chips

In an interview with SF2DON on 5/12/14 at 3:32 p.m., he verified the chips Patient #F6 was being given were not allowed on an ADA diet. He also reviewed the care plans for Patient #F1, Patient #F4, Patient #F5 and Patient #F6 and agreed patient care plan interventions were not being implemented because the snacks being administered were not allowed on the prescribed 1800 calorie ADA diets.

Based on interview and record review, the hospital failed to ensure nutritional needs were met in accordance with orders of the practitioners responsible for the care of the patients as evidenced by 6 (#F1- #F6) of 6 (#F1-#F6) patients reviewed not receiving their 1800 calorie ADA (American Diabetes Association) diets as ordered.

Findings:

Patient #F1
Review of the medical record for Patient #F1 revealed he was admitted on 4/30/14 with diagnosis which included Schizophrenia and Diabetes mellitus.

Review of the admission order sheet for Patient #F1 dated 4/30/14 at 5:15 p.m. revealed an order for an 1800 calorie ADA diet.

Review of the Dietary Intake and Output Sheets for Patient #F1revealed the following entries:
5/3/14- Morning Snack: Cookies; Evening Snack: Chips
5/4/14- Morning Snack: Cookies
5/5/14- Evening Snack: Cookies
5/6/14: Morning Snack: Chips
5/7/14: Morning Snack: Oreos; Evening Snack: Cookies and Chips
5/8/14: Morning Snack: Shortbread Cookies
5/9/14: Evening Snack: Cookies

In an interview on 5/12/14 at 12:21 p.m. with SF3Dietician said diabetic menus consisted of three meals, an a.m. snack ( choices: SF (Sugar Free) Jello, SF pudding, Crystal Light and/or 3 graham cracker squares) and a bedtime snack ( 1/2 sandwich and/or skim milk ). She confirmed chips, cookies (Oreos, Shortbread) and Chex mix were not appropriate snacks for a 1800 calorie ADA diet.

In an interview with SF2DON on 5/12/14 at 1:50 p.m., he verified the Oreos, Shortbread Cookies and Chips Patient #F1 was being given were not allowed on an ADA diet. SF2DON said, after review of the Dietary Intake and Output Sheets, " So we're giving them the wrong diet and controlling their blood sugar with insulin."

Patient #F2
Review of the medical record for Patient #F2 revealed he was a 51 year old male admitted on 5/1/14 with diagnosis which included Bipolar I Depression severe with psychosis. Further review of the psychiatric evaluation revealed the physician documented the patient had "Hyperglycemia with DM (?)". (Diabetes Mellitus)

Review of a physician's order dated 5/2/14 at 7:50 a.m. for Patient #F2 revealed an order for NCS (no concentrated sweets) for now. In an interview on 5/12/14 at 12:21 with SF3Dietician, she said NCS diet meant the same at the hospital as an 1800 calorie ADA diet.

Review of the Dietary Intake and Output Sheets for Patient #F2 revealed the following entries:
5/2/14- Morning Snack: Carmel Popcorn; Evening Snack: Chips
5/3/14- Morning Snack: Cookies
5/4/14- Morning Snacks: Cookies
5/5/14- Morning Snack: Chips
5/6/14- Lunch: Cake
5/7/14- Morning Snack: Oreo; Dinner Evening Snack: Oreos, Pretzels

In an interview with SF2DON on 5/12/14 at 1:52 p.m., he verified the diet Patient #F2 was being given was not an ADA diet.

Patient #F3
Review of the medical record for Patient #F3 revealed she was admitted on 5/3/14 with diagnosis which included Schizoaffective disorder and Diabetes mellitus.

Review of the admission order sheet for Patient #F3 dated 5/3/14 at 2:20 a.m. revealed an order for an 1800 calorie ADA diet.

Review of the Dietary Intake and Output Sheets for Patient #F3 revealed the following entries:
5/3/14- Morning Snack: Cookies; Evening Snack: Chips
5/4/14- Morning Snack: Cheese Crackers; Evening Snack: Chips

In an interview with SF2DON on 5/12/14 at 1:52 p.m., he verified the diet for Patient #F3 was not the ADA diet the patient was prescribed because cookies and chips were not diabetic snacks.

Patient #F4
Review of the medical record for Patient #F4 revealed she was admitted on 5/3/14 with diagnosis which included Depressive Type Psychosis and Diabetes mellitus.

Review of the admission order sheet for Patient #F4 dated 5/3/14 at 11:01 a.m. revealed an order for an 1800 calorie ADA diet.

Review of the Dietary Intake and Output Sheets for Patient #F4revealed the following entries:
5/3/14- Evening Snack: Chips
5/4/14- Morning Snack: Cookies
5/5/14- Morning Snack: Chips; Evening Snack: Chips
5/6/14: Morning Snack: Chex Mix

In an interview with SF2DON on 5/12/14 at 1:53 p.m., he verified the Cookies, Chex mix and Chips Patient #F4 was being given were not allowed on an ADA diet.

Patient #F5
Review of the medical record for Patient #F5 revealed he was a 44 year old male admitted on 5/2/14 with diagnosis which included Schizoaffective Disorder and Diabetes Mellitus.

Review of the Physician's Admission Orders for Patient #F5 dated 5/2/14 at 8:20 p.m. revealed an order for an 1800 calorie ADA diet and a low Sodium Diet.

Review of the Dietary Intake and Output Sheets for Patient #F3 revealed the following entries:
5/2/14- Evening Snack: Chips
5/3/14- Morning Snack: Cookies; Evening Snack: Chips

In an interview on 5/12/14 at 3:30 p.m. with SF2DON, he verified chips and cookies were not part of a diabetic diet.

Patient #F6
Review of the medical record for Patient #F6 revealed she was admitted on 5/6/14 with diagnosis which included Depression and Diabetes Mellitus.

Review of the admission order sheet for Patient #F6 dated 5/6/14 at 7:00 p.m. revealed an order for an 1800 calorie ADA diet.

Review of the Dietary Intake and Output Sheets for Patient #F6 revealed the following entries:
5/7/14- Evening Snack: Chips
5/8/14- Evening Snack: Chips

In an interview with SF2DON on 5/12/14 at 3:32 p.m., he verified the Chips Patient #F6 was being given were not allowed on an ADA diet.

In an interview on 5/12/14 at 5:30 p.m. with SF7DietaryManager she confirmed chips, cookies (Oreos, Shortbread) and Chex mix were not appropriate snacks for an 1800 calorie ADA diet.







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