At 1930, assumed care after receiving report from offgoing nurse. Patient observed in bed, awake, alert, and oriented ×4. Telemetry displayed sinus rhythm. Patient reported head pain rated 6/10 and declined offered ordered analgesics. Patient oriented to room and use of call light.

Assumed care of new patient after receiving report from offgoing nurse. Patient observed in bed, awake, alert, and oriented ×4. Patient stated, “I did not receive my dinner tray.” Kitchen confirmed closed for the night and no sandwiches available. Snacks provided from unit supply. Patient denied pain when asked. Blood glucose obtained at 2347 measured 347 mg/dL. Ordered insulin administered per MAR. Blood glucose rechecked at 0011 measured 411 mg/dL. Nocturnist NP notified of blood glucose values and missed dinner tray. Orders received. Ordered insulin held per provider order. Additional blood glucose documented at 2347 measured 347 mg/dL. Telemetry displayed sinus tachycardia with heart rate in the 110s. Patient asymptomatic.

At 0200, report received from break nurse. Patient observed resting in bed. Respirations observed even and unlabored with visible chest rise and fall. Wound care completed per existing orders at this time. Call light within reach. Bed in low position with wheels locked.