Failure to Notify Physicians and Follow Orders
Penalty
Summary
The facility failed to notify a physician of abnormal glucose readings and lab results for three residents, and did not follow physician orders for two residents. Resident R67, who was admitted with conditions including atrial fibrillation and coronary artery disease, had high blood sugar levels recorded on two occasions without the physician being informed, contrary to the physician's orders. Additionally, the facility did not notify the LVAD team of a supratherapeutic PT/INR result, which was required by the resident's care plan. Resident R77, diagnosed with high blood pressure, diabetes, and cancer, had multiple instances of low blood sugar readings without physician notification or documented interventions. The resident's care plan included specific instructions for managing hypoglycemia, but these were not followed, and there were no parameters set for administering glucose treatments during hypoglycemic events. Resident R115, admitted with renal insufficiency and heart failure, had an incorrect transcription of a medication order for Bumex, which was supposed to be administered at a higher dose. This error was identified but not corrected in a timely manner. The Director of Nursing and the Nursing Home Administrator confirmed these failures in communication and adherence to physician orders, which contributed to the deficiencies noted in the report.
Plan Of Correction
Facility is unable to retroactively correct concern of lack of assessment of the residents for signs/symptoms of hypoglycemia or hyperglycemia. Director of Nursing and/or designee reviewed the blood glucoses with the attending physicians for all listed residents. Resident R67 remains at the facility. Resident R67 was seen on 1/16/2025 and no negative outcome was identified. Resident R115 has been discharged as planned with no negative outcomes. All residents receiving blood sugars will have a retroactive 14-day review of blood sugars with notifications to physicians as necessary. R67's PT/INR results will be communicated to the LVAD team as ordered and reviewed with attending physician when new orders are received. A one-week retroactive review of all new admissions will be audited to ensure that orders have been transcribed correctly. The Director of Nursing or designee will educate licensed nurses on facility's policies for assessing for change in condition, physician notifications, hypoglycemia, and medication and treatment orders. The Director of Nursing or designee will audit CBG monitoring summaries for residents who require CBG testing and ensure resident assessment and physician notifications are made when an abnormal CBG is recorded. These audits will be completed on all CBG residents daily x 3 days, then a random five CBG residents three times weekly x 2 weeks and then weekly for 2 months. All new admissions will be audited to ensure orders are transcribed correctly three times weekly x 3 months. All notifications of PT/INR's for LVAD team notifications will be audited three times weekly for two weeks, then weekly for two months. All results to be reviewed through QAPI for further recommendation.