Failure to Follow Hypoglycemia Protocol and Physician Orders Results in Immediate Jeopardy
Summary
The facility failed to administer care in a manner that ensured effective and efficient use of resources to maintain the highest practical well-being of each resident, as evidenced by the handling of a resident experiencing hypoglycemia. The resident, who had a history of Type 2 Diabetes Mellitus and was under orders for regular blood glucose monitoring and emergency glucagon administration for low blood sugar, experienced a series of hypoglycemic episodes. On one occasion, the resident's blood sugar was found to be 72, and an LPN administered glucose gel without a physician's order and did not notify the provider. Subsequently, the resident became less responsive, and later, a critically low blood sugar of 42 was recorded. The on-call physician was contacted and ordered glucagon administration, monitoring, and transfer to the emergency room if there was no positive response. Despite these orders, when the resident's blood sugar dropped again to 50 and then to 32, glucagon was not administered as directed, the provider was not notified, and the resident was not sent to the emergency room as per the physician's instructions. Documentation was incomplete, and there was a lack of timely and appropriate follow-up on the resident's deteriorating condition. Interviews with staff and review of records revealed that the nurse did not document all blood sugar checks, did not follow the expected protocol for hypoglycemia management, and lacked documented competency training regarding glucagon administration. The DON and other clinical leaders were not promptly informed, and the incident was not identified as a reportable event or brought to the facility's QAPI process in a timely manner. The resident ultimately became unresponsive and was transported to the hospital, where they did not survive. The facility's failure to implement its policies and procedures for change in condition, notify the physician as required, and follow physician orders for hypoglycemia management resulted in a determination of Immediate Jeopardy. This deficiency placed all residents at risk who might experience a change in condition requiring prompt and appropriate intervention.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received one on one education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated.
- VPCS (Vice President of Clinical Services) reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions.
- The Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and hour report review during clinical standup and stand down meeting, and maintaining QA/PI (Quality Assurance/Performance Improvement) process.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The NHA and DON failed to manage the facility effectively to protect a resident known to be at risk for elopement. A resident exited the assigned nursing unit unsupervised, and the report states this created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks. The NHA and DON confirmed the administrative failure during interview.
Ineffective administration led to multiple failures in fall management, staffing, nutrition, immunization education, and abuse prevention. The facility did not follow fall interventions or complete accurate fall assessments and investigations, and two residents sustained serious injuries, including rib fractures and a thoracic burst fracture after an improper transfer. The report also cites inadequate RN coverage, insufficient staffing, missed dialysis transport, inaccurate documentation, falsified bathing records, failure to provide snacks and adaptive equipment, and abuse-related issues including verbal abuse and misappropriation of resident funds and property.
Failure to Timely Report Abuse and Neglect Allegations: The facility failed to maintain an effective system for timely reporting allegations of abuse and neglect after a prior F609 citation for the same issue. Surveyors found nine late reports involving multiple residents, and staff and the administrator acknowledged ongoing difficulty tracking when reports were due, with most late reports occurring during the monitoring period after the earlier deficiency.
A resident with dementia and wandering tendencies was not protected from elopement after staff failed to follow instructions to place a Wander Guard and move him to the Secured Memory Unit. The resident was seen in the lobby, later could not be located, and was found miles from the facility after leaving unsupervised; the front entry door also lacked an operational Wander Guard system.
Failure to Ensure Supervision and Elopement Prevention: The facility failed to consistently supervise and maintain safety interventions to prevent elopement for residents. Review of records, job descriptions, and staff interviews showed the NHA and DON did not effectively manage the facility to ensure proper supervision and elopement prevention interventions were implemented, and they failed to fulfill their essential duties to ensure federal and state guidelines and regulations were followed.
Unqualified Social Service Director Hired: The facility failed to ensure the Social Service Director met the stated qualification of a bachelor's degree and 1 year of social services experience. The Administrator stated the current SSD was still in school and had not completed her degree, while a behavioral health director with a degree only helped with social services at times and was not the SSD. The job description and facility policy did not align with current regulatory requirements, and the facility census was 182 residents.
Failure to Protect a Known Elopement Risk
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to protect residents from elopement. Review of the facility’s job descriptions showed that the NHA was responsible for supervising department heads, ensuring compliance with regulatory guidelines, and reviewing complaints and trends, while the DON was responsible for directing nursing services, coordinating care, overseeing staffing, and investigating and reporting incidents and complaints. Despite these responsibilities, the facility failed to prevent and protect residents from exiting their assigned nursing unit unsupervised. The deficiency involved Resident R1, who was documented as an elopement risk. Survey findings showed that R1 exited the resident’s assigned nursing unit without supervision. During an interview, the NHA and current DON confirmed that facility administration failed to effectively manage the facility to protect residents from elopement. The report states that this failure created an Immediate Jeopardy situation for one of fourteen residents documented as elopement risks.
Ineffective Administration Affecting Falls, Staffing, Nutrition, Immunizations, and Abuse Prevention
Penalty
Summary
The facility failed to administer operations in a manner that used resources effectively and efficiently, with ineffective administration affecting multiple residents across several care areas. The report states that the facility did not maintain effective systems for fall prevention and accident hazard control, including failure to follow fall interventions and the smoking policy, and failure to complete accurate fall assessments, investigations, and care plans. These issues affected Residents #6, #9, #24, #56, #113, and #115, and the report notes actual harm to Resident #56, who sustained multiple right and left rib fractures, a hematoma to the right chest wall, bruising across the breasts, right flank, back, both arms, both sides of the ribs, and both legs, with no actual determination of the cause of injuries. The report also describes a serious injury to Resident #113 after a fall from bed, when staff inappropriately transferred the resident and she was thrown onto the bed. The resident sustained a thoracic burst fracture and multiple ecchymoses on both hands, wrists, forearms, and upper extremities. In addition, Residents #6, #9, #24, and #115 had falls with inadequate investigations, incomplete documentation, updated care plans, and inaccurate assessments. The facility also failed to provide effective dietary services by not ensuring substantial snacks for the secured memory care unit, honoring food preferences, and providing needed adaptive equipment, affecting Residents #29, #49, #80, #83, #86, #96, and #99. Other findings included inadequate nursing services and staffing, with no RN coverage at least eight hours daily and insufficient staffing to meet resident needs, affecting Residents #6, #12, #13, #16, #39, #40, #45, #88, #93, #99, and #110. The report states that nursing staff did not implement care-planned interventions for Resident #45, did not follow discharge instructions or provide timely incontinence care for Resident #13, did not ensure dialysis transport for Resident #106, did not accurately document advance directives for Resident #93, and did not accurately transcribe a physician order that led to a significant medication error for Resident #88; it also states that bathing documentation for Resident #88 was falsified. Additional deficiencies involved an ineffective immunization program for Residents #9, #24, #32, and #72, and failures in abuse, neglect, misappropriation, and exploitation prevention, including verbal abuse toward Resident #93, misappropriated funds from Resident #61, misappropriated personal property from Resident #117, unnecessary medications for Residents #25 and #30, and delayed abuse reporting and investigations for Residents #56, #82, #93, and #117.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure an effective system for timely reporting allegations of abuse and neglect after a previous F609 deficiency for the same concern. Based on interview and record review, the facility continued to submit late reports for allegations involving 9 of 19 residents, identified as residents 4, 5, 9, 10, 11, 12, 13, 14, and 16. The report states that the late reporting placed residents at risk for delays in notification, investigation, protection, and response following allegations of abuse or neglect. A prior F609 deficiency dated 1/29/26 showed the facility had already been cited for late reporting of allegations of neglect and abuse for three residents. During an interview on 7/29/26, staff member A stated, "I'm still learning . there's been a lot going on here ." The administrator also stated, ". I need to develop a system, so I know when they are due." The current complaint investigation found that the facility administrator and staff continued to report allegations throughout the plan of correction monitoring period, and eight of the nine late reports occurred between 2/22/26 and 5/22/26.
Failure to Protect Resident from Elopement
Penalty
Summary
The facility administration failed to manage the facility in a manner that protected residents and safeguarded them from elopement. The Administrator and DON job descriptions stated they were responsible for directing and overseeing facility operations in accordance with federal, state, and local regulations, but the facility was aware that the front entry door did not have an operational Wander Guard system and corrective measures were not implemented. The report identified this as an Immediate Jeopardy related to F689 and F835, with the noncompliance beginning on July 16, 2026. Resident 1 was admitted with a dementia diagnosis and an elopement assessment was completed on admission, with staff noting wandering tendencies and that the resident was suitable for the Secured Memory Unit. On July 16, 2026, the resident was seen in his room at 3:30 AM, then in the front lobby at 4:30 AM, and was later unable to be located at 5:45 AM. The elopement protocol was initiated at 6:10 AM, and the resident was found about one hour later three miles from the facility. The Administrator stated the resident had been instructed to be placed on a Wander Guard device and moved to the Secured Memory Unit, but those instructions were not followed. The receptionist also stated she did not recognize the resident as a resident and thought he was a visitor.
Failure to Ensure Supervision and Elopement Prevention
Penalty
Summary
The facility failed to consistently supervise and maintain safety interventions to prevent elopement for residents. Based on review of facility records and job descriptions, and staff interviews, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper supervision and elopement prevention interventions were implemented. The NHA job description stated that the NHA directs the overall operations of the care community in accordance with current local, state, and federal regulations to ensure the highest level of quality care is provided to each resident, and the DON job description stated that the DON manages and directs resident care within the nursing department to maintain resident standards of care and ensure each resident functions at his/her highest level. The report states that the NHA and DON failed to fulfill their essential job duties to ensure federal and state guidelines and regulations were followed.
Unqualified Social Service Director Hired
Penalty
Summary
The facility failed to administer the facility by failing to ensure a qualified individual was hired as the social service director. During interview, the Administrator stated the requirement for the social services director was a minimum of a bachelor's degree and 1 year of experience in social services, and stated that the current Social Service Director, V4, was still in school and had not completed her bachelor's degree. The Administrator also stated she did the hiring and hired V4 in collaboration with the facility consultant. The Administrator further stated that a behavioral health director helped with social services at times, but that person had a degree and was not the social service director. The facility's Social Service Director job description listed qualifications of a high school diploma or GED and knowledge of federal and state LTC social service regulations, and the facility policy did not align with current regulatory requirements for the position. The Facility Assessment Tool dated 7/13/26 identified a Social Service Director as a needed resource, and the staffing plan included one social service director, one social service designee, and one behavioral health director. The Facility Data Sheet dated 7/24/26 showed a census of 182 residents.
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