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Based on interview, record review, and facility policy review, the facility failed to ensure nursing staff developed a nursing care plan that reflected the patient's goals and the nursing care to be provided to meet the patient's needs for 1 (Patient #3) of 3 sampled patients reviewed for care plans. The failure resulted in the patient's glucose not being monitored or managed.

Findings include:

A facility policy titled, "Plan of Care," dated 08/2019, showed, "Procedure: I. The plan of care will be initiated within 12 hours of admission ..."

A "History and Physical Report[s]," dated 12/14/23, showed Patient #3 was admitted on 12/13/23 for further workup and treatment after going to the emergency room for abnormal laboratory tests and an inflamed small bowel.
An "Arrival on Unit" record, dated 12/14/23 at 12:20 AM, showed Patient #3 arrived to the 2 South unit on 12/14/23 at 12:03 AM.

An "IPOC [Interdisciplinary Plan of Care]" flowsheet for Patient #3 showed the IPOC for "Unstable Glucose" was initiated on 12/14/23 at 5:23 PM.

During an interview on 12/04/24 at 9:47 AM, Senior Director of Nursing (SDON) #1 stated that the "Unstable Glucose" care plan for Patient #3 was initiated on 12/14/23 at 5:23 PM. SDON #1 stated there was no other documentation by the nurse about glucose monitoring or diabetes management for the patient.

Based on interview, record review, and facility policy review, the facility failed to ensure licensed staff adhered to the policies and procedures of the hospital for 1 (Patient #1) of 3 sampled patients reviewed for insulin administration. The failure resulted in a medication administration discrepancy.

Findings include:

A facility policy titled, "Guidelines for Nursing Practice," dated 08/2023, showed, " ...F. All insulin dosages are verified by a second nurse. This verification should include checking the MAR [medication administration record] with the insulin vial(s) and actual dosage drawn up..."

A "History and Physical Report[s]," dated 10/16/24, showed Patient #1 was admitted on 10/16/24, for new onset type two diabetes mellitus and hyperglycemia.

Patient #1's "Orders" flowsheet showed an order dated 10/18/24, for insulin lispro 12 units with meals.

A "Medication Administration Record" flowsheet showed Patient #1 received eight units of insulin lispro on 10/18/24 at 5:20 PM, and no dual verification was documented.

During an interview on 12/03/24 at 10:41 AM, Senior Director of Nursing (SDON) #1 stated that eight units of insulin was administered to Patient #1 on 10/18/24 at 5:20 PM. SDON #1 stated that she did not see a note as to why the nurse gave eight units instead of 12 unit. SDON #1 stated that a dual sign off was not required for insulin , and the documentation should have flagged the incorrect dose.

During an interview on 12/03/24 at 1:30 PM, Registered Nurse (RN) #9 stated that she did not recall the incident when Patient #1 received eight units of insulin lispro.

During an interview on 12/03/24 at 2:27 PM, RN #9 acknowledged there was not a second nurse that verified the dosage of insulin administered to Patient #1. RN #9 stated that short-acting insulin was drawn up by the nurses independently, and the long-acting insulin was drawn up and sent by the pharmacy.

During an interview on 12/03/24 at 3:46 PM, SDON #1 stated that the facility policy did not require the documentation of dual verification for insulin, that there was a spot that allowed for it in the record, but it was not required. SDON #1 stated that documentation of dual verification would not be seen in Patient #1's record or any other insulin administration because it was not required by the policy.