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F0580
J

Failure to Notify Physician of Change in Condition and Resident Refusal of Insulin

Milford, Ohio Survey Completed on 04-09-2025

Penalty

Fine: $53,370
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when facility staff failed to notify the physician or nurse practitioner in a timely manner following a significant change in a resident's condition. The resident, who had a complex medical history including Type I diabetes mellitus, end-stage renal disease, and a tracheostomy, was found to have an extremely elevated blood glucose level. Although the nurse practitioner was initially notified and additional insulin was ordered, the resident refused the insulin. The nurse did not inform the physician or nurse practitioner of the resident's refusal, nor were any further blood glucose checks performed or documented. Subsequently, the resident was found on the floor, unresponsive to questions, with noticeable swelling on the right side of the face. Despite these findings, no neurological assessment was completed, and there was no notification to the physician or nurse practitioner regarding the resident's change in condition. The resident remained in this state until the following morning, when staff found the resident unresponsive with bluish skin tone, abdominal breathing, and significant head edema. Emergency services were called, and the resident was transported to the hospital. At the hospital, the resident was diagnosed with acute encephalopathy, multiple metabolic and infectious abnormalities, and acute metabolic acidosis, with a blood glucose level exceeding 784 mg/dL. The resident ultimately died. Interviews and record reviews confirmed that neurological checks were not performed and that neither the physician nor the family were notified of the resident's change in condition until after the resident was sent to the hospital.

Removal Plan

  • Resident was sent to the ED with notification made to the physician.
  • Administrator and Minimum Data Set (MDS) Nurse reviewed the 24-hour report and self-identified a concern with resident's refusal of an order for insulin and failure to notify the physician/nurse practitioner during clinical meeting.
  • Administrator and RDCO obtained statements and conducted interviews with relevant staff.
  • RDCO was notified by Administrator of the situation and arrived at the facility to assist with the investigation.
  • RN/Staff Development Coordinator (SDC) assessed all residents who had a recent fall and completed a neurological check.
  • LPNs and RDCO assessed all residents for a change in condition.
  • Administrator suspended DON pending investigation for failure to notify Nurse Practitioner of resident's refusal to be administered insulin and subsequent change in condition. DON was terminated from employment.
  • RN/SDC provided all nurses, medication technicians, and CNAs with education related to fall assessment protocols, notification of physicians for resident change of condition, the importance of initiating treatment, the importance of rounding every two hours, the importance of obtaining neurological checks when it was suspected the resident had a head injury and/or was on blood thinners, and the importance of initiating the risk management application in the electronic medical record.
  • RDCO and Administrator notified facility Medical Director of the incident and reviewed the policy and procedure for change in condition/notification of change.
  • A Quality Assurance and Performance Improvement (QAPI) meeting was held with Administrator, RDCO, and Medical Director. The policy for change in condition/physician notification was reviewed with no recommended revisions. The result of the facility's root cause analysis (RCA) was reviewed and the staff completed education was reviewed.
  • RN and LPNs completed walking rounds for resident change in condition. One resident was found with a change in condition, and it was addressed.
  • RDCO reviewed all resident blood sugars to ensure notification of variances was made to the physician.
  • RDCO/designee provided education on resident change in condition and notification to the physician/nurse practitioner to all newly hired nurses and CNAs.
  • RDCO/designee conducted a daily clinical meeting to review residents with a change in condition and/or transfer to the hospital to ensure proper physician notification was made timely. The clinical meetings continue indefinitely.
  • RDCO/designee monitored the results of the daily clinical meeting for residents with a change in condition and notification to the physician and submitted the findings to the QAPI committee for review and recommendations. This continued monthly with QAPI meetings and then as needed.
  • Two additional resident medical records were reviewed for change in condition and notification of change with no concerns identified.
  • Staff interviews verified they received education from the facility regarding a resident change in condition or mental status change from the resident's baseline.
See complete original report
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