Failure to Document and Notify Hypo/Hyperglycemic Events
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address previously cited deficiencies, specifically concerning the documentation and notification of hypo/hyperglycemic events. The review of the facility's policy and plan of correction from a previous survey indicated that the facility had developed a plan to ensure compliance with nursing home regulations. However, the current survey identified repeated deficiencies related to the documentation of blood sugar levels and timely notification to the medical director. Multiple residents were affected by the facility's failure to document and notify medical personnel of blood sugar levels outside of ordered parameters. For instance, one resident was sent to the hospital for a change in condition without a blood sugar reading being obtained as per protocol. Another resident had a blood sugar result of 59, but the note was placed 48 hours later. Several other residents had high blood sugar results with no documentation or notification to the medical director, indicating a systemic issue in following the established protocol. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the facility's failure to maintain an effective Quality Assurance Committee to address these concerns. The deficiencies have the potential to affect 26 of the 84 residents, highlighting a significant lapse in the facility's management and oversight of critical health indicators.
Plan Of Correction
The NHA/DON will conduct a root cause analysis for F 684 from the 1.13.25 survey. Those results will present to the facility QAPI for review and will provide guidance to the plan of correction. To prevent recurrence, the NHA/designee will implement a plan of correction including correction of the practice for residents identified in the citation F 684, identification and correction as needed of other residents who have the potential to be affected, system correction including education on the diabetic protocol, the hypoglycemia policy, and the change in condition policy including hyperglycemia is a change of condition to the licensed nurses. Ongoing monitoring of blood sugar results and care plans for diabetic residents to maintain compliance will be conducted by the DON/designee. The facility's QAPI members will be educated on the QAPI policy by the NHA/designee. Weekly reviews with the QAPI team of the plan of correction audits for the citations from the 1.13.25 survey x 5 weeks and monthly for 2 months and recommendations will be made as needed if noncompliance identified.