Failure to Ensure Proper Diabetes Management for Resident
Summary
The facility failed to ensure that a resident with Diabetes Mellitus (DM) received appropriate treatment and care in accordance with professional standards of practice. Upon admission from a General Acute Care Hospital (GACH), the facility did not verify all discharge orders for diabetes management with the attending physician. The resident, who had a history of DM and was receiving insulin prior to admission, did not have orders for blood sugar monitoring or insulin administration upon arrival at the facility. This oversight persisted throughout the resident's six-day stay at the facility, during which the resident's blood sugar levels were not monitored, and no insulin was administered despite the resident's known condition and previous treatment regimen at the GACH. The resident's care plan included instructions to monitor for signs and symptoms of hypoglycemia and hyperglycemia, but there was no documented evidence that this monitoring occurred. The Medication Administration Record (MAR) showed that the resident was administered Sitagliptin daily, but there were no records of blood sugar monitoring or any communication with the physician regarding the need for such monitoring. On the sixth day, the resident was found unresponsive and was transferred to the GACH via 911, where they were diagnosed with Diabetic Ketoacidosis (DKA) and had a critically high blood sugar level of 823 mg/dL. The resident was admitted to the ICU, where they received an insulin drip and vasopressin but ultimately expired six days later. Interviews with facility staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed that there was a lack of communication and verification of the resident's diabetes management orders upon admission. The DON and other staff members acknowledged that there were no orders to monitor the resident's blood sugar or administer insulin, and they did not take steps to verify these orders with the attending physician. The facility's policies and procedures for diabetic care, admission, and physician orders were not followed, leading to the resident's critical condition and subsequent death.
Penalty
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Surveyors found that the facility did not review and implement hospital discharge instructions for two residents who used respiratory support devices. One resident with chronic respiratory failure and sleep apnea had a CPAP machine in the room and reported using it at night, but there was no corresponding physician order, care plan entry, or MDS documentation. Another resident with COPD and chronic kidney disease had an AVAP machine with detailed hospital transfer orders specifying pressure settings, respiratory rate, tidal volume, and O2 bleed-in parameters, yet no physician orders for AVAP use were entered in the medical record. The CNO confirmed that orders for both devices were missing, placing these residents at risk of delayed respiratory care and assessments.
A resident admitted for orthopedic aftercare following surgical amputation, with a history of kidney transplant and difficulty walking, arrived from the hospital with discharge orders for non–weight-bearing status to the right lower extremity and a requirement for a private room due to immunocompromised status from immunosuppressive medication. These orders were not transcribed into the facility’s physician orders, and thus non–weight-bearing and isolation precautions were not implemented. The DON reported that admission orders from the hospital were expected to be reviewed and clarified before arrival, but acknowledged that the admission nurse did not complete this review, leading to the omission.
A resident was admitted from the hospital with discharge paperwork that contained conflicting information about an IV Ceftriaxone order, which was listed as both discontinued in one area and as an active discharge order in another. The IV antibiotic was never started on the resident’s MAR, and the DON later reported that the resident was on hospice, had no IV access, and was not receiving IV antibiotics. Despite the facility policy requiring verification of any order that appears inappropriate for the resident’s condition, the admitting nurse did not contact the physician to clarify the admission orders.
A resident admitted with severe cognitive impairment, multiple neurologic and metabolic diagnoses, and a gastrostomy feeding tube had enteral feeding orders and a baseline care plan documenting dependence on tube feeding, but no physician order was obtained for Enhanced Barrier Precautions (EBP) from admission through the initial days of stay. Interviews with the DON, ADON, and Administrator confirmed that a feeding tube is considered an indwelling or invasive device under facility policy and that such residents require an EBP order, and record review verified that no such order was present despite staff reportedly following EBP practices.
A resident with type 2 DM, malnutrition, and severe cognitive impairment was admitted on oral sitagliptin but did not receive physician orders for HbA1c monitoring every 6 months or capillary blood glucose checks at least twice weekly, as required by the facility’s diabetes protocol. The DON confirmed that no blood glucose monitoring orders were in place, and record review showed no blood sugar assessments for over a year after admission. The attending MD reported that an order set for HbA1c monitoring should have been automatically placed for residents on oral diabetic medications but was not entered for this resident. The resident was later transferred to a hospital with altered mental status and weakness, where labs showed a blood glucose level greater than 800 mg/dL.
A resident admitted with hemiplegia and hypertension did not receive several ordered medications for three days because hospital discharge medication orders were not properly verified or transcribed. The DON later acknowledged confusion over multiple hospital medication lists and confirmed that key drugs for BP control, pain, blood thinning, and cardiac/BP management were omitted from the MAR. The admitting LVN located faxed discharge orders in the electronic record but did not contact the admitting MD to verify or clarify the admission orders and did not document any physician communication. The MD reported he was not contacted at admission, despite facility policy requiring documentation of receipt and verification of physician orders, and the resident was subsequently transferred to the hospital for syncope.
Failure to Implement Respiratory Device Orders on Admission
Penalty
Summary
The facility failed to ensure hospital discharge instructions were reviewed upon admission so that physician orders were in place to meet residents’ medical needs. One resident with chronic respiratory failure with hypoxia and obstructive sleep apnea was admitted with a CPAP machine present in his room and reported using it at night. Surveyors observed the CPAP machine on the resident’s dresser, and the resident confirmed nighttime use. However, the Chief Nursing Officer (CNO) later stated that there was no physician order for the CPAP, and it was not included on the resident’s care plan or Minimum Data Set (MDS), despite the resident’s diagnoses and reported use of the device. Another resident admitted with COPD and chronic kidney disease had an AVAP machine at bedside and stated she used it at night to help her breathe while sleeping. Review of this resident’s hospital transfer orders documented detailed AVAP settings, including IPAP and EPAP ranges, respiratory rate, tidal volume, and oxygen bleed-in parameters with humidification and SpO2 targets, as well as instructions for use each night. Despite these specific hospital discharge instructions, review of the resident’s medical record on a later date showed no physician orders for AVAP use. The CNO confirmed that the AVAP was not on the resident’s orders and acknowledged it should have been, and the survey findings stated that this failure placed the residents at risk of delayed respiratory care and assessments.
Failure to Implement Hospital Discharge Orders for Weight-Bearing and Isolation Status
Penalty
Summary
The facility failed to ensure that physician orders from a transferring hospital regarding weight-bearing status and isolation needs were accurately transferred and implemented for one admitted resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status requiring immunosuppressive medication, and difficulty in walking. Hospital discharge orders dated 10/09/25 included a non–weight-bearing order for the right lower extremity and a requirement for a private room due to immunocompromised status related to the kidney transplant. Review of the resident’s physician orders at the facility showed that the non–weight-bearing status for the right lower leg and the isolation precautions related to immunosuppressive medication were not present. In an interview, the DON stated that the resident should have had these physician orders in place per the hospital discharge instructions and that her expectation was that all hospital admission orders be reviewed and clarified before the resident’s arrival. The DON confirmed that the admission nurse did not review and clarify these admission orders, and as a result, they were not implemented.
Failure to Clarify Conflicting Admission Orders for IV Antibiotic
Penalty
Summary
The facility failed to clarify and implement admission medication orders for one resident when the resident was admitted from the hospital. The hospital discharge packet dated 12/13/25 included a discharge order for Ceftriaxone 2 grams IV every 24 hours through 1/2/26, but the resident’s December 2025 MAR shows that this IV antibiotic order was not initiated on the admission date. The DON stated that the resident returned from the hospital on hospice and, to his knowledge, did not have IV access and was not receiving IV antibiotics. Upon reviewing the hospital discharge packet, the DON noted that in one section the antibiotics were documented as discontinued, but in another section Ceftriaxone was listed under discharge orders, and acknowledged that the admitting nurse should have called to clarify the conflicting orders. The facility’s policy on physician orders for medications or treatments, dated 6/2022, requires that any dose or order that appears inappropriate considering the resident’s age, condition, or diagnosis be verified with the attending physician, which was not done in this case.
Failure to Obtain Physician Order for Enhanced Barrier Precautions at Admission
Penalty
Summary
Surveyors identified a deficiency in that the facility failed to obtain physician orders for a resident’s immediate care related to Enhanced Barrier Precautions (EBP) at the time of admission. The resident was an older male admitted with multiple significant diagnoses, including cerebral infarction, metabolic encephalopathy, dysphagia, cognitive communication deficit, muscle wasting and atrophy, and gastrostomy status with a feeding tube in place. The resident’s MDS showed severe cognitive impairment with a BIMS score of 4 and documented use of a feeding tube on admission. The baseline care plan indicated the resident required tube feeding and was dependent on staff for tube feeding and water flushes, and the order summary reflected an active enteral feeding order starting on the admission date. Record review showed that from admission through several days afterward, there were no physician orders for EBP, despite the resident having a feeding tube, which the facility’s policy defined as an indwelling medical device requiring an EBP order. The DON stated that the resident required EBP since admission due to the feeding tube and acknowledged that no EBP order was in place, although staff were aware of and followed EBP. The ADON confirmed that residents with feeding tubes required EBP because the tube was an invasive device and that the team was supposed to review physician orders for accuracy. The Administrator also stated that residents with feeding tubes needed EBP orders and that the team reviewed new admission orders to ensure they were in place. The facility’s EBP policy specified that an order for EBP would be obtained for residents with wounds or indwelling medical devices, including feeding tubes, even if they were not known to be infected or colonized with MDROs.
Failure to Obtain Diabetic Monitoring Orders for a Resident on Oral Hypoglycemics
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain and implement physician orders for hemoglobin A1C monitoring every 6 months and blood glucose capillary/fingerstick assessments at least twice weekly for one resident with type 2 diabetes. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and malnutrition and was prescribed oral sitagliptin. The resident’s MDS dated 2/14/25 documented severe cognitive impairment with a BIMS score of 6/15. Review of the admission record and the Order Listing Report showed no physician orders for A1C monitoring or blood glucose testing at admission or thereafter, despite the facility’s Diabetes Clinical Protocol requiring the provider to order glucose targets and monitoring regimens, including A1C on admission and every 6 months and at least twice-weekly blood glucose monitoring for residents on oral diabetic medications who are well controlled. The DON confirmed during interview that a physician’s order is required to perform blood glucose capillary/fingerstick testing and acknowledged that the resident had no such orders, even though it was important to assess blood glucose to determine blood sugar status and monitor the treatment plan. The attending MD stated that residents with stable type 2 diabetes on oral medications should have an order set in the EHR for A1C monitoring every 6 months and that this was a standard order set automatically placed on admission, but the resident did not receive it for reasons the MD could not explain. Medical Records and the Administrator reported that the MD had access to the facility EHR but used a personal EHR system, with relevant documents uploaded monthly by Medical Records. Review of the resident’s Weights and Vitals Summary showed no blood sugar assessments between admission on 3/11/24 and 3/18/25. The resident was later admitted to a general acute care hospital with altered mental status, including lethargy, confusion, partial responsiveness, and weakness, where labs showed a blood glucose level greater than 800 mg/dL.
Failure to Verify and Transcribe Admission Medication Orders
Penalty
Summary
The facility failed to ensure a resident’s hospital discharge medication orders were verified with the admitting physician upon admission, resulting in inaccurate transcription and missed medications. The resident was admitted with multiple diagnoses including hemiplegia and essential hypertension. The hospital’s short-term Medicare referral and discharge documents included an active medication list and discharge orders. The DON later acknowledged being confused by multiple medication lists from the hospital and confirmed that several discharge medications were not transcribed onto the admission orders or MAR and therefore were not administered for three days. The medications omitted included Amlodipine for blood pressure, Buprenorphine for pain, Clopidogrel as a blood thinner, and Hydralazine for heart and blood pressure management. The resident’s responsible party met with the DON and expressed concerns about missing medications on the MAR. The admitting LVN stated the resident did not arrive with paper discharge orders and that he located the discharge orders via fax in the electronic record and used them to create admission orders, but he did not contact the admitting physician to verify or clarify those orders. The LVN also did not document any contact with the physician regarding admission orders. The resident’s primary physician, who was the admitting physician, reported he was not contacted by nursing staff at the time of admission and stated he expected licensed nurses to verify and clarify admission orders upon admission. Facility policy on admission documentation required the admitting nurse to document the time physician orders were received and verified, but there was no documentation that this occurred for this resident, and the resident did not receive the ordered medications for three days, culminating in a transfer to the hospital for syncope.
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