HospitalInspections.org

Based on interview and record review, the facility failed to ensure that the registered nurse evaluated the patient's blood sugar and/or nutritional intake for 1 (#11) of 7 patients reviewed for blood sugars/intake evaluation, resulting in the potential for unsatisfactory outcomes. Findings include:

On 4/1/19 at approximately 1400, record review revealed that patient #11 was a 51-year-old male admitted to facility B on 2/22/19 at approximately 1616 (4:16 PM). He had a history of acute respiratory failure, hypoglycemia, known diabetic with history of dialysis, previous cardiac arrest, coronary artery disease, hypertension, sepsis, and multiple other comorbidities. Electronic orders dated 2/22/19 had 1912 (7:12 PM) specified 'Insulin Regular for sliding scale...before meals and at bedtime (4 times/day);' and a Diet order on 2/22/19 at 1952 (7:52 PM), 'Carb controlled, Mech Soft, thin liquids (easy to chew and swallow).' The first blood sugar documented at 1645 (4:45 PM) was 108. No dinner was documented as given. No bedtime blood sugar was documented. The next blood sugar reported was a critical value at thirty-one (31) drawn from the lab and reported to nursing on 2/23/19 at approximately 0720.

Interviews with the Quality Director BB, Pharmacy Director HH, and Dietitian II on 4/1/19 at between 1500 to 1630, revealed that the facility had done a Root Cause Analysis (problem solving method) and had educated staff and implemented most of the action plans.

On 4/2/19 at approximately 0900, interview with the day shift Nursing Supervisor MM revealed that he received the critical value blood sugar call on the morning of 2/23/19. Staff immediately checked on the patient and a code blue was called which included cardiopulmonary resuscitation (CPR). The patient had return of spontaneous circulation (ROSC) and was transferred to the ICU (intensive care unit) of the host acute care hospital.

Nurse PP who cared for the patient on the evening of 2/22/19 (7PM to 7AM) was interviewed via phone, on 4/2/19 at approximately 1100, and she stated that she was unaware that the patient had not eaten and was not aware that a bedtime blood sugar had not done. She stated, "I remember checking on the patient frequently (every half hour to an hour)... he had abdominal pain." She had given him pain medication with relief. On 4/2/19 at approximately 1200, interview with the Patient Care Tech (PCT) RR who took care of the patient upon admission (shift 7AM to 7PM) revealed that she did not recall the patient. She stated that she normally takes the vital signs and blood sugars and notifies the nurse. The nurse would notify her if the patient needed to be fed. The admitting nurse was not available for interview.

On 4/2/19 at approximately 1500, review of the facility policy titled "Assessment/ Reassessment/ Care Planning, H-NS 052, dated 1/18" documented, "RN... Delegates, supervises and coordinates all elements of the initial assessment process... the RN may perform all or certain designated assessment functions, based on his/her evaluation of the patient's condition... Reviews all data elements including those compiled by the LPN, PCT and CNA (other nursing staff members) to determine and set priorities for the patient's nursing care needs..."