Encompass Health Rehabilitation Hospital of Shreve

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 17450 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by 1) failing to assess and timely treat a patient with a low blood sugar (Patient #1), 2) failing to clarify orders for glucose level results (Patient #2) and 3) failing to perform glucose checks and administer sliding scale insulin as ordered by the physician (Patient #3) for 3 sampled patients. Findings: 1) Failing to assess and timely treat a patient with a low blood sugar (Patient #1) Review of the medical record for Patient #1 revealed an admission date of 12/27/2025 at 1:54 PM and a discharge date of 12/28/2025 at 5:00 AM. Review of admitting diagnoses included insulin dependent diabetes, end stage renal disease and recent toe amputation. Review of admission orders revealed they included routine insulin daily, Glipizide 10mg twice daily (antidiabetic), glucose checks before meals and at bedtime and to obtain a peripheral IV. Review of the patient’s documented glucose checks revealed the following: 12/27/2025 at 4:51 PM, result of 101 (normal level between 80-130) 12/27/2025 at 9:38 PM, result of 71 12/28/2025 at 4:28 AM, result of 10 12/28/2025 at 4:49 AM, result of 21 Review of the medical record revealed that the nurse administered Glipizide on 12/27/2026 at 8:53 PM. There were no documented nursing assessments of the patient after the glucose level of 71 was obtained on 12/27/2025 at 9:38 PM until the next morning at 4:28 AM, when the glucose was a low level of 10. There was no documented evidence that the patient received a bedtime snack on the evening of 12/27/2025, after having a low glucose level prior to bedtime. Further review of the medical record revealed that prn Glucagon (used to treat low glucose levels) was not administered until 12/28/2025 at 4:39 AM, 11 minutes after obtaining the patient’s dangerously low glucose level. Review of nurses notes dated 12/28/2025 revealed at 4:30 AM, the tech informed the nurse that the patient’s glucose level was 10. The patient was unresponsive. At 4:50 AM, glucagon was administered and physician was notified. IV attempted twice and unable to obtain. 911 was called, dextrose was administered and patient left via EMS unresponsive. On 04/29/2026 at 3:00 PM, interview with S1CNO confirmed there was no documented assessments of the patient after the glucose level of 71 was obtained on 12/27/2025 until the next morning at 4:28 AM, when the patient’s glucose level was 10. S1CNO confirmed the patient should have received a bedtime snack on the evening of 12/27/2025, but there was no documentation of this. S1CNO further confirmed the patient had an order for a peripheral IV upon admit, but there was no documented evidence that this was obtained and as a result, the staff were unable to obtain IV access when the patient was found in an emergent state with a low blood sugar on 12/28/2025. S1CNO confirmed that 11 minutes was too long to wait to administer Glucagon after finding the patient with a glucose level of 10. 2) Failing to clarify orders for glucose level results (Patient #2) Review of the medical record revealed an admission date of 04/24/2026 with diagnoses including status post right hip fracture and diabetes. Review of the history and physical dated 04/25/2026 revealed the plan included “tight blood pressure and glucose control”. Review of admission orders revealed they included glucose checks before meals and at bedtime. There was no sliding scale insulin ordered upon admit. Review of the patient’s documented glucose checks revealed the following high results: 04/25/2026 at 11:55 AM, result of 182 04/25/2026 at 4:59 PM, result of 200 04/25/2026 at 8:40 PM, result of 171 04/26/2026 at 9:21 PM, result of 180 04/27/2026 at 10:36 AM, result of 194 04/27/2026 at 7:08 PM, result of 176 04/28/2026 at 7:23 PM, result of 213 04/29/2026 at 10:40 AM, result of 183 Review of the medical record revealed no documented evidence that the physician was notified of the high glucose levels. There was no documented evidence that the nurses had clarified the lack of sliding scale insulin orders. On 04/29/2026 at 12:15 PM, interview with S2RN Supervisor confirmed that the patient’s physician had not been contacted to clarify if he wanted to order sliding scale insulin. S2RN Supervisor further stated that the nurses use their own judgement on whether to contact the physician regarding high blood glucose levels. On 04/30/2026 at 11:00 AM, interview with S3Physician revealed that the patient was on tight glucose control. S3Physician stated that he thought the patient was receiving sliding scale insulin per protocol since admit, stating that the nurses should have initiated the sliding scale insulin protocol in the plan of care by diagnosis or clarify the order with him.. When asked if he was aware of the patient’s higher glucose results, he stated no. S3Physician further stated that the patient should have been receiving sliding scale insulin since admit. 3) Failing to perform glucose checks and administer sliding scale insulin as ordered by the physician (Patient #3) Review of the medical record revealed an admission date of 04/23/2026 with a diagnosis including diabetes. Review of admission orders revealed they included glucose level checks before meals and at bedtime with sliding scale insulin to be administered. Review of the sliding scale insulin protocol revealed insulin is given when the glucose levels reach 150 and above. Review of the patient’s documented glucose checks and sliding scale insulin revealed they included the following: 04/24/2026, no bedtime glucose result documented 04/27/2026 at 12:24 AM, result of 225 but no evidence of sliding scale insulin administered 04/27/2027 at 8:44 PM, result of 165 but no evidence of sliding scale insulin administered 04/28/2026, no bedtime glucose result documented On 04/30/2026 at 11:00 AM, interview with S1CNO confirmed the above missing glucose checks and sliding scale insulin administration.”