Failure to Notify Providers of Out-of-Range Blood Sugar Levels
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to address previously cited deficiencies related to the notification of medical providers for out-of-range blood sugar levels. Despite having a plan of correction in place, the facility did not ensure compliance with the established protocols for notifying physicians when residents' blood glucose levels were outside the set parameters. This deficiency was identified during a survey, which revealed that the facility had not effectively implemented its QAPI program to correct these issues. The survey findings highlighted specific instances where residents with elevated blood sugar levels did not have documented notifications to their medical providers. For example, one resident had multiple instances of elevated blood sugar readings, some as high as 600 mg/dL, without any record of provider notification. Similar patterns were observed with other residents, indicating a systemic issue in the facility's process for managing and communicating critical health information. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to maintain an effective Quality Assurance Committee. This failure to address the concerns related to blood sugar management had the potential to affect 18 out of 91 residents, demonstrating a significant gap in the facility's quality assurance processes.
Plan Of Correction
Facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care. The Facility will maintain a Quality Assurance Performance Improvement (QAPI) plan according to regulation in order to ensure that the Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. To identify other areas potentially affected, the Facility will develop and implement appropriate plans of action to correct quality deficiencies and regularly review and analyze data, including data collected under the QAPI program and data specifically related to monitoring residents with sliding scale orders to ensure blood sugar values are reviewed, documentation of physician notification per ordered parameters, and evidence of follow-up and resident response to abnormal readings. To prevent this from happening again, the Nursing Home Administrator or designee will educate the Interdisciplinary Team and Quality Assurance Performance Improvement (QAPI) Committee to ensure the facility's Quality Assurance Performance Improvement program, and its participants, implement effective systems to correct quality deficiencies and ensure that plans effectively address recurring deficiencies. The Quality Assurance Performance Improvement (QAPI) committee will meet weekly for four weeks, then monthly for two months to ensure plans of correction and audit tools are effective. All licensed nursing staff will receive mandatory in-service training by the DON on interpreting provider-specific glucose parameters, timely physician notification procedures, documentation expectations, and diabetes management protocol by 4/30/25. The facility NHA will monitor corrections, education, and ongoing monitoring to ensure that plans are effective to address recurring deficiencies. The DON/designee will conduct audits five times per week for four weeks, then three times per week for two weeks on residents' EMR with blood sugar out of range, which contains documentation of physician notification per ordered parameters, evidence of follow-up, and resident response to abnormal readings. The NHA will submit reports to QAPI on compliance of audits. To monitor and maintain ongoing compliance for action plans related to providing quality care by monitoring resident blood glucose monitoring and ensuring appropriate interventions are implemented, the results from auditing and ongoing monitoring reviewed at the Quality Assurance Performance Improvement meetings will be reviewed by the Regional Clinical Operations Director to ensure adequate implementation of QAPI plans to maintain ongoing compliance. The DON/designee will submit a report to QAPI on the compliance with notification of physicians on high or low blood sugar levels. This will be done for a period of two months.