Failure to Maintain Adequate Nursing Staff and Monitor Resident with Diabetes
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the needs of all residents, resulting in a deficiency that directly affected one resident and had the potential to impact others. On the day in question, the facility did not have the required number of licensed nurses on duty due to call-offs and scheduling issues. The staffing plan called for at least three LPNs or RNs on dayshift, but only two nurses were present, and attempts to secure additional coverage were unsuccessful. Communication breakdowns occurred between the nightshift nurse, the Director of Nursing, the Administrator, and Human Resources, leading to confusion about who was responsible for medication administration and resident care during the shift change. A resident with type I diabetes and a history of unstable blood glucose levels experienced significant lapses in care. The resident did not receive scheduled blood sugar checks or insulin administration as ordered by the physician. Documentation showed that the resident's blood sugar was not monitored for an extended period, and there was no evidence that insulin was administered when indicated. The resident was later found on the floor in her room, lying in vomit, with critically low blood pressure, irregular pulse, and severe hyperglycemia. Staff were initially unaware of the resident's whereabouts, and it was only after a search that she was located and assessed. The resident was subsequently transferred to the emergency department, where she was diagnosed with diabetic ketoacidosis, high anion gap metabolic acidosis, acute urinary tract infection, non-ST elevated myocardial infarction, and sepsis. The facility's failure to provide adequate staffing and ensure proper monitoring and care for the resident's complex medical needs contributed to the adverse outcome. The deficiency was further evidenced by the lack of a root cause analysis for the resident's fall and the absence of timely interventions in response to her deteriorating condition.