HospitalInspections.org

Based on a review of documentation and staff interviews, the facility failed to ensure that nursing services were provided in a safe environment and in accordance with facility policies and procedures.

Findings were:

Policy entitled "Patient Rights and Responsibilities" states in part, "#9. You have the right to: Reasonable responses to any reasonable requests made for the service. #14. Receive care in a safe setting. Free from mental, physical, sexual, or verbal abuse and neglect, exploitation or harassment. You have the right to access protective services and advocacy services including notifying government agencies of neglect or abuse. #16. Reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the persons providing the care."

Policy entitled "Rapid Response Team Standing Orders:" states in part, "5.14 Symptomatic Hypoglycemia:
5.14.8 Notify Physician ASAP if hypoglycemia Protocol is initiated.

Review of patient#1 medical record revealed the nursing staff failed to follow hospital policies and procedures. Staff # 4 failed to notify the physician ASAP (as soon as possible) when she initiated Hypoglycemic protocol at 1350 on 11/28/19. At 1455 physician and charged nurse in patient's room. At 15:01 patient's spouse called 911 and the patient was transported via EMS (emergency medical system) ambulance to an Acute Health Care facility.

The above findings were confirmed in an interview the afternoon of 02/28/2018 with the Facility Director of Nursing and in the facility conference room.

Based on a review of documentation and staff interviews, the facility's Nursing Service Director failed to demonstrate responsibility for the operation of nursing services. There were conflicting blood glucose parameters regarding notification of the physician on the adult insulin orders and the blood glucose testing hospital policy.

Findings were:

Policy entitled "Blood Glucose Testing" Reviewed April 2017, Pages 3. Policy states in part, "#10. Note the test results in the appropriate blood glucose section of the patient's graphic record. For results less than 50 or greater than 400, go to step 11.
#11. A comment code MUST BE entered on the meter for results out of the action range. Select one of the following out of range action comments:
" #0 No action required
" #1 Repeat test
" #9 Notified nurse
" #10 Notified Physician.
#12. FOR ALL GLUCOSE LESS THAN 50 OR GREATER THAN 400, PHYSICIAN WILL BE NOTIFIED."

Facility document entitled "Subcutaneous Adult Insulin Orders" states in part, "6. Hypoglycemia (BG <60 mg/dl) Follow protocol below and contact physician."



The above physician orders revealed conflicting parameters regarding notification of the physician in comparison to the blood glucose testing hospital policy. The facility policy stated "FOR ALL GLUCOSE LESS THAN 50 OR GREATER THAN 400, PHYSICIAN WILL BE NOTIFIED."

In an interview with the Director of Nursing he stated, "There were some issues with the Abbott glucometer. The reading on the glucometer was set up for readings up to 60 mg/dl. It was not set to reply for an automatic response. We were not aware of this issue and we immediately took action to correct the problem. The reading on the glucometer was not programed to read lower than 60 mg/dl. If the blood glucose is lower than 60 mg/dl it will prompt the staff to repeat the test, notify the physician. compared to the blood glucose testing policy. The Abbott glucometer are now programed to read blood glucose levels between 50 mg/dl to 400 mg/dl."

The above findings were confirmed in an interview the afternoon of 02/28/2018 with the Facility Director of Nursing and in the facility conference room.