HospitalInspections.org

Based on policy review, medical record review, and interview the facility failed to document the results of blood glucose testing (blood sugar level) of one patient (#2) of 5 patients reviewed.

The findings included:

Review of the facility's policy titled, "Record of Care, Treatment and Services - Medical Record Documentation" dated 9/2009 revealed, "...It is the policy of Parkridge Medical Center, Inc to have a complete medical record for each patient's episode of care, treatment and services...Documentation reflects the patient's care, treatment, and services and includes, but not limited to...Results of diagnostic and therapeutic tests and procedures..."

Medical record review revealed Patient #2 was admitted to the hospital's psychiatric campus on 8/4/2022 with diagnosis that included Severe Bipolar Disorder. Review of a physician's order dated 8/5/2022 revealed an order for, "...Glucose Level, Monitor...Frequency: BID [twice a day] with meals..." Review of the Point of Care[bedside] Glucose Monitoring results revealed only one results was documented on 8/6/2022, 8/8/2022, and 8/11/2022. Continued review of the record revealed no documentation of the blood glucose monitoring being performed a second time on 8/6/2022, 8/8/2022, and 8/11/2022. Continued review revealed no documetation of the patient refusing the testing or being out of the hospital at those times.

Interview with the Marketing Director Quality Standards on 8/18/2022 at 2:00 PM in the Psychaitric Campus Conference Room revealed Patient #2 had a physician's order for blood glucose monitoring twice a day. Continued interview confirmed there was no documentation of Patient #2's blood glucose monitoring being performed a twice on 8/6/2022, 8/8/2022, and 8/11/2022. Continued interview revealed Patient #2 should have had blood glucose monitoring twice a day as ordered and the results documented in the medical record. Continued interview revealed there was no documentation of why the blood glucose monitoring was not performed twice a day on those dates.

Based on policy review, Food Storage Refrigerator/Freezer Log Sheet review, observations, and interviews, the facility failed to store food and food products in a safe manner.

The findings included:

Review of facility policy titled, "Floor Supplies (Inpatient)" dated 3/2008 revealed, "...Items requiring refrigeration...Will be delivered and placed in the refrigerator on the nursing unit...Nursing is responsible for refrigerator sanitation and daily monitoring and documentation of refrigerator temperatures...Verification of refrigerator temperatures is logged by a member of Nursing staff one time per day. Temperature log is to be located on each refrigerator..."

Observations of the patient food storage refrigerator in the 100-200 dayroom on 8/18/2022 at 12:15 PM revealed there were no refrigerator or freezer temperatures recorded on:
8/3/2022
8/4/2022
8/11/2022
8/12/2022
8/13/2022

Interview on 8/18/22 at 12:15 PM with the Marketing Director for Quality Standards in the 100-200 Dayroom revealed the refrigerator in the dayroom contained food for patient use. Continued interview revealed the refrigerator and freezer temperatures are to be monitored each day and documented on the log sheets. Continued interviewed confirmed the 100-200 Dayroom refrigerator and freezer temperatures had not been documented on:
8/3/2022
8/4/2022
8/11/2022
8/12/2022
8/13/2022

Observations of the patient food storage refrigerator in the 300-400 dayroom on 8/18/2022 at 12:45 PM revealed there were no refrigerator temperatures recorded on:
8/11/2022
8/12/2022
8/13/2022
8/15/2022

Interview on 8/18/22 at 12:45 PM with the Marketing Director for Quality Standards in the 300-400 Dayroom revealed the refrigerator in the dayroom contained food for patient use and its temperatures are to be monitored each day and documented on the log sheets. Continued interviewed confirmed the 300-400 Dayroom refrigerator temperatures had not been documented on:
8/11/2022
8/12/2022
8/13/2022
8/15/2022