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Based on interview and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidence by:

1. failing to ensure that Patient #1 had reassessments performed after a change in condition and/or abnormal lab results;

2. failing to ensure to activate a Rapid Response Team (RRT) after being aware of Patient #1's unresponsiveness; and

3. failing to ensure that Patient #1 had a timely transfer to a higher level of care.

Cross Refer to Tag 0395

Based on interview and record review, the facility's registered nurse (RN) did not supervise and evaluate the nursing care of each patient in that 1 of 1 patient (Patient #1) was found to be unresponsive on 07/04/18 at 8:00 AM, and eventually transferred to a hospital at 9:40 AM, after an hour and 40 minutes of unresponsiveness.


Findings included:


Patient #1 was admitted on 06/25/18 for "acute metabolic encephalopathy with COPD steroid-induced myopathy...causing decline in functional status with frequent falls." Patient #1 had chronic diastolic congestive heart failure, poorly controlled type 2 diabetes mellitus, and was oxygen-dependent.


The "Flowsheet" from 06/25/18 through 07/04/18 indicated, Patient #1's glucose level via glucometer readings (POC/point of care) ranged from 15 to >600 (critical values <60 and >400). The laboratory results of glucose serum ranged from 227 to 925 (reference range/ref range 70 to 110).


On 07/02/18, the Nurse's Notes indicated, Patient #1 agreed to eat at 8:15 PM. Her capillary blood glucose (CBG) was checked 2 hours later as ordered. Her CBG was >600. Physician #3 was notified. A new order was received for Novolog 3 units. Physician #3 stated "you can recheck blood sugar later, but do not call to notify me. Order read back, and verified, carried out, insulin administered at 10:59 PM...blood sugar rechecked at 12:22 AM [07/03/18], 534mg/dL." No reassessment was conducted. The primary care nurse did not notify a registered nurse regarding above findings.


On 07/04/18, the Nurse's Notes indicated, Patient #1's CBG was >600 at 9:42 PM. Physician #3 was notified. A new order was received at 10:09 PM for Novolog 4 units. Physician #3 stated "you may recheck blood sugar later, but don't call to notify me unless blood sugar is low." No reassessment was conducted. The primary care nurse did not notify a registered nurse regarding above findings.


Speech Language Pathology Notes on 07/04/18 at 8:00 AM indicated, "Patient [#1] unresponsive despite max verbal cueing and sternal rub. Notified patient nurse of inability to wake patient.


The Nurse's Notes on 07/04/18 at 8:28 AM, indicated, "...Therapy brought to nurse's attention that Patient #1 is non responsive as of 0800. Patient has pulse of 156 and temperature of 102.8 axillary. Supervisor has been informed as well as Physician #3. Stat acetaminophen ordered to be administered suppository. Suppository administered...Patient remains in deep sleep despite multiple attempts to awake..."


The Nurse's Notes on 07/04/18 at 8:30 AM, indicated, Patient #1 was lying in bed breathing "a little bit faster and warm to touch. I tried to wake her up tapping her shoulder and wiping her face with wet wash cloth but she did not wake up." The patient's vital signs were taken. Her BP was 156/78, HR-156, RR-24 and temperature was 102.5. Her CBG read "high." She had diminished breath sounds. Physician #3 was around and ordered blood cultures and Invanz one dose IM. "...After an hour of trying to wake the patient she still did not open her eyes. Physician #3 suggested to call Physician #9 to transfer the patient out due to unresponsive, elevated temp and possible going septic..." Patient #1 was transferred to a local acute hospital at 9:40 AM, after an hour and 40 minutes of unresponsiveness.


During an interview on 07/23/18 at 11:45 AM, with Personnel #2 she said, she was out of town at the time of the transfer, but she was notified of the transfer after her return. She didn't know any details about Patient #1, but the incident would be reviewed on the first Friday of August (August 3, 2018). Personnel #1 stated, Patient #1's CBG should have been re-checked 30 minutes to an hour after the administration of insulin. It was unacceptable for a physician to tell a nurse not to notify him/her of abnormal lab results.


During an interview on 07/23/18 at 12:58 PM, with Personnel #8, she confirmed she reported to the nurse that Patient #1 was difficult to arouse even after a sternal rub.


During an interview on 07/23/18 at 1:55 PM, with Personnel #4, she confirmed she cared for Patient #1 on 6 PM (07/02/18) to 6 AM (07/03/18) shift. Personnel #4 said, when she called Physician #3 and reported the patient's elevated blood sugar, he gave an order to give the patient insulin. The patient's blood sugar could be rechecked, but Physician #3 instructed Personnel #4 not to call him back unless Patient #1's CBG was low.


During an interview on 07/23/18 at 2:05 PM, with Personnel #5, she confirmed she was working on the morning of 07/04/18. She said, she went into Patient #1's room after the nurse reported that the patient couldn't be aroused. Patient #1 was breathing and Physician #3 was in the room. She wasn't sure if the Rapid Response Team (RRT) was called. A Tylenol suppository was ordered for the patient. "Physician #3 said yesterday she was like this but she woke up after a while." We tried to wake her but she wouldn't wake up. "We thought maybe the patient could be in a hyperglycemic coma, but the doctor was there so we just did what he said."


During an interview on 07/23/18 at 2:33 PM, with Personnel #6, she confirmed she cared for Patient #1 on 07/04/18 on the 6 AM-6PM shift. She received a bedside report for Patient #1. She was told her CBG was elevated and she had received medication. Personnel #6 stated, she attempted to give the patient her morning medications but she didn't wake up. "I thought she was ignoring me like she did before." Personnel #6 left the patient without giving her the medications. Later a therapist reported to Personnel #6 that Patient #1 couldn't be arouse. Personnel #6 went into the patient's room and found the patient to be unresponsive. She did a sternal rub on the patient but she remained unresponsive. Personnel #6 reported the patient's condition to the supervisor. When asked what Personnel #6 would normally do when she found a diabetic patient unresponsive, she said, she would call a code and the supervisor. Personnel #6 didn't call a code, she only called the supervisor. Physician #3 was in the hospital and came to the room. A Tylenol suppository was ordered and given to the patient. Personnel #6 did not ask Physician #3 why he thought the patient was unresponsive.


Facility policy "Assessment and Reassessment" reviewed 05/17/18 required, "II. Reassessments are performed by each discipline according to the patients' vital signs, laboratory results, status or condition...IV. Reassessment across all disciplines is ongoing..." The primary care nurses did not adhere to the facility policy and procedure.


Facility policy "Change in Patient Condition" reviewed 02/21/18 required, "Responsibility 1. Staff nurse taking care of the patient...Will provide background information to the Rapid Response Team (RRT) regarding the patient's condition...Nurse in charge...Will provide clinical expertise, and provide advance assessment skills and support for the bedside nurse, as well as facilitate a more timely transfer to a higher level of care..." The primary care nurse and nurse supervisor did not adhere to the facility policy and procedure.