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Based on record review, staff interview, review of job descriptions, and review of policy, it was determined the facility failed to ensure physician orders were followed to obtain a blood sugar level for for one (Patient #1) of 10 patients reviewed. The patient census was 16.

Findings include:

Review of the medical record for Patient #1 revealed an admission to the psychiatric hospital on 09/26/24 around 9:00 PM. Diagnoses included psychosis and diabetes mellitus Type 2.

Review of physician orders on admission included the diabetic medication metformin hydrochloride 500 milligram (mg) twice a day. Orders dated 09/27/24 included obtain blood sugar (BS) checks in the morning and at bedtime (HS). Notify the physician if BS is less than 60 milligram/deciliter (mg/dl) and greater than 350 mg/dl. On 09/28/24 the diabetic medication glyburide 10 mg daily was ordered. The medical record revealed no documentation the BS was obtained as ordered on 09/27/24 and 09/28/24.

Interview on 11/25/24 at 10:21 AM the Director of Nursing/Chief Executive Officer (DON/CEO), verified Patient #1 had orders for blood sugars in the morning and at bedtime and to notify the physician if the BS was less than 60 or greater than 350 mg/dl. The DON/CEO stated the orders did not pull over to the medication administration record. MAR.

Review of the Charge Nurse Job Description, dated 01/10/24, revealed the charge nurse duties and responsibilities including ensure the provider's orders are followed.

Review of the policy titled "Blood Glucose Testing, Policy No: NR.22," last revised 03/2024, included the purpose was to provide guidelines for proper use and maintenance of whole blood glucometers to diagnoses hypoglycemia or hyperglycemia. The policy states results will be documented in the patient's medical record.