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Based on interview and record review the facility failed to insure the patient's primary Resistered Nurse followed the facilit's Policy and Procedure in that the Hypoglycemia Questionnaire was not done on two of four records reviewed.

Findings include:

Policy Review:

Review of the current facility policy H-MM 08-002 titled "Management of Hypoglycemia", Release Date 06/2017; Purpose: The procedure provides guidelines for safe, prompt treatment of hypoglycemic episodes. Policy: 3) The hypoglycemic protocol is used to provide a rapid and effective response to unexpected drops in the patient's blood glucose. It is followed for patients with fingerstick glucose levels less that 70 mg/dL. Procedure: If the results is below 50 mg/dL: follow facility's Critical Value policy. Do Not delay treatment. 4) Follow treatment of the hypoglycemic event, a Hypoglycemia Questionnaire will be completed for facility quality review. a. Form will be completed by primary nurse assigned to patient or designee, b. Forward the complete form to the Director of Quality Management for analysis and facility committee review.

Interview:

An interview on 02/07/2019 at 2:00 p.m. with Chief Clinical Operator (CCO), Employee ID #51 stated that a Hypoglycemia Questionnaire should be filled out by the patients nurse any time the patient's blood sugar drops below 50 mg/dL. Record review of patient's ID #4 medical records along with Employee ID #51 the Hypoglycemia Questionnaire form was not found in the medical record. No additional document was received prior to leaving the facility.

Record Review:

Medical record review on 02/07/2019 at 1:00 p.m. of Patient ID #4 blood sugar records documents 4 episodes of blood sugar levels less than 50 mg/dL. Record review showed on 12/22/18 a fingerstick blood sugar of 46 mg/dL and on 12/30/2018 a fingerstick glucose level of 44 mg/dL. No Hypoglycemia Questionnaire form was found in the patient's medical record for 12/22/18 or 12/30/2018.