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Based on record review and interview, the registered nurse failed to evaluate the nursing care for each patient by failing to notify the physician for treatment when the fingerstick blood sugar was elevated for 1 (#3) of 5 (#1-5) patients with orders for fingerstick blood glucose monitoring.
Findings:

Review of the physician orders for Patient #3 revealed he was admitted from home on 10/11/21 with diagnoses including uncontrolled diabetes. Review of the physician orders revealed he was to have accuchecks before meals and at bedtime. There was no documented evidence that orders were given for sliding scale insulin administration.

Review of the Diabetic Record for Patient #3 revealed the following elevated blood sugar readings:
10/20/21 11:00am (204) - no insulin given, no evidence of physician notification;
10/20/21 4:00pm (217) - no insulin given, no evidence of physician notification;
10/20/21 8:30pm (287) - no insulin given, no evidence of physician notification;;
10/21/21 9:00pm (272) - no insulin given, no evidence of physician notification;;
10/22/21 11:00am (221) - 3 units noted - no documented order obtained for administration;
10/22/21 4:00pm (217) - 3 units noted - no documented order obtained for administration;
10/23/21 11:00am (281) - 4 units noted - no documented order obtained for administration;
10/23/21 4:00pm (286) - 4 units noted - no documented order obtained for administration;
10/23/21 8:00pm (351) - no insulin given, no evidence of physician notification;;
10/24/21 11:00am (279) - no insulin given, no evidence of physician notification;;
10/24/21 8:00pm (256) - no insulin given, no evidence of physician notification;;
10/25/21 8:00pm (204) - no insulin given, no evidence of physician notification;

On 10/26/21 at 2:30pm, an interview with S6RN House Supervisor confirmed there were no orders received upon admission for sliding scale insulin to be administered for ac and hs fingersticks, no evidence that the physician was notified with the elevated blood sugar readings, and no evidence that orders were obtained when the insulin doses were administered. He further confirmed that the physician should be notified when blood sugar levels are above 200 and there are no sliding scale orders to administer insulin.

Based on record review and interview, the RN failed to ensure the nursing care of each patient was assigned to other nursing personnel in accordance with the specialized qualifications and competence of the available nursing care staff. This deficient practice was evidenced by:

1) assigning a LPN to care for an unstable patient on a Diprovan drip that was being titrated for 1(S4LPN) of 3 (S2RN, S3RN, S4LPN) nurses reviewed for Diprovan administration; and

2) failing to have annual training for conscious sedation as required by the Louisiana State Board of Nursing for 2 (S2RN, S3RN) of 2 RNs and 1 (S4LPN) of 1 LPN reviewed for Diprovan administration.

Findings:

Review of the LSBN's "Declaratory Statement On The Role And Scope Of Practice Of The Registered Nurse In The Administration Of Medication And Monitoring Of Patients During The Levels Of Intravenous Procedural/Conscious Sedation (Minimal, Moderate, Deep, And Anesthesia) As Defined Herein" revealed that it is within the scope of practice for a RN to administer non-anesthetic medications, up to and including moderate (conscious sedation), and to monitor patients in minimal, moderate, and deep sedation levels provided the RN is specifically trained and demonstrated knowledge, skills, and abilities in accordance with the following provisos in various settings to include inpatient and outpatient environments. The RN (non-certified registered nurse anesthetist) shall have documented education and competency to include the following: knowledge of sedative drugs and reversal agents, their dosing, onset, duration, potential adverse reactions, drug compatibility, contraindications, and physiologic effects; Advanced Cardiac Life Support; skill in establishing an open airway, head-tilt, chin lift, use of bag-valve-mask device, oral and nasal airways, and emergency procedures including rescuing a patient that may progress beyond deep sedation; demonstration of the acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition; the ability to recognize complications of undesired outcomes related to sedation/analgesia; appropriate interventions in compliance with standards of practice, emergency protocols or guidelines; demonstration of the knowledge of age specific considerations in regard to assessment parameters, potential complications, and appropriate interventions according to institutional protocol or guidelines; possession of the requisite knowledge and skills to perform and evaluate pre-procedure baseline, intra-procedure, and post-procedure clinical assessment of the patient undergoing sedation/analgesia; demonstration of the ability to use oxygen delivery devices, applying the principles of oxygen delivery and respiratory physiology; demonstration of the knowledge of the standards of practice and licensure related to the sedation/analgesia; application of the principles of accurate documentation in providing a comprehensive description of patient responses and outcomes. Competencies will be measured initially during orientation and at least on an annual basis.

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703 revealed the RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation:
a) nursing care ordered and directed by the RN or physician requires abilities based on a
relatively fixed and limited body of scientific fact and can be performed by following a
defined nursing procedure with minimal alteration, and responses of the individual to the
nursing care are predictable; and
b) change in the patient's clinical conditions is predictable; and
c) medical and nursing orders are not subject to continuous change or complex
modification.

Review of Patient #5's medical record revealed he was admitted on 08/10/2021 and expired on 08/14/202. His diagnosis included severe acute respiratory mechanical ventilation with intubation, COVID-19 Pneumonia, Severe Anemia, Severe Hypoxia, Diabetes and Hypertension. S5MD documented on Patient #5's Discharge Summary that on 08/13/2021he was on 100% Oxygen per Ventilator and his saturations were in the range of 80-83%. He started having a GI bleed with a moderate amount of bleeding from his mouth that required a NG tube to suction. He was also placed prone to improve saturations.

1) Assigning a LPN to care for an unstable patient on a Diprovan drip that was being titrated.

Review of Patient #5's medical record revealed he was on Diprovan on 8/13/2021 and 08/14/2021. Further review revealed 3 nurses had documented on the Diprovan Titration flowsheet. The nurses were S2RN, S3RN and S4LPN. S4LPN was assigned to Patient #5 on the night shift of 08/13/2021 and morning of 08/14/2021.

In an interview on 10/26/21 at 1:43 p.m. with S1DON, he verified on 08/13/2021 S4LPN was assigned to Patient #5. He also verified Patient #5 was on Diprovan and should not have been assigned to a LPN. He also verified that S4LPN's initials were on the Diprovan titration documentation in Patient #5's medical record.

2) Failing to have annual training for conscious sedation as required by the Louisiana State Board of Nursing.

Review of concious sedation competencies for S2RN revealed she had been deemed competent in March of 2013. Further review revealed no other competencies for concious sedation.

Review of concious sedation competencies for S3RN revealed he had been deemed competent in September of 2014. Further review revealed no other competencies for concious sedation.

In an interview on 10/26/21 at 1:43 p.m. with S1DON, he verified S2RN and S3RN only had conscious sedation competencies on hire and have not had any annual cometencies on conscious sedation since. S2RN was hired on 3/13 and S3RN was hired 9/14. He verified S4LPN did not have competencies on conscious sedation because he should not be monitoring it. S1DON said he did not reaize the RNs needed an annual competency.