F0684

D

Failure to Assess, Treat Hyperglycemia, and Document Change in Condition After Family Concern

Burlington, New Jersey Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess and provide needed care and services after a reported change in condition for one resident. The resident had multiple significant diagnoses, including sepsis, COPD, type 2 diabetes mellitus, and diastolic congestive heart failure, and had an MDS BIMS score indicating intact cognition. On the evening in question, the resident’s family approached the nursing station and reported to an LPN that the resident “looked septic.” The LPN documented that she notified the RN supervisor, who assessed the resident and obtained vital signs showing BP 142/101, HR 126, pulse oximetry 97, blood sugar 438 mg/dL, temperature 98.1°F, and respiratory rate 17. The LPN’s progress note stated that the MD was notified and that the family insisted the resident be sent to the hospital, after which 911 was called and the resident was transferred.

Record review showed that, despite the elevated blood sugar of 438 mg/dL and an active sliding scale insulin order (151–200=2 units; 201–250=4; 251–300=6; 301–350=8; 351–400=10; 401–450=12 units SC every 6 hours), there was no evidence that insulin was administered in response to this blood sugar level. The Weights and Vital Summary confirmed the blood sugar of 438 mg/dL documented that evening, but there was no corresponding medication administration documented to show that staff followed the sliding scale order. Additionally, the summary showed that the last documented temperature, respirations, pulse, and oxygen saturation were taken earlier in the day on the 7–3 shift, with only a blood pressure documented at 18:30, and no further vital signs recorded after the family’s report of concern, other than what was referenced in the LPN’s note.

Further, there was no documentation in the medical record of the RN supervisor’s assessment findings beyond what the LPN recorded, and no documentation of the time the physician was notified or any orders received regarding the high blood sugar. In interview, the LPN stated she did not remember if any interventions were done prior to EMS arrival. The RN supervisor acknowledged that she assessed the resident, including lung sounds (which she described as diminished) and noted the resident looked frail, but admitted she did not document her assessment and stated she should have done so. The DON stated that the expectation was that any supervisor assessment, especially when a resident is sent to the hospital, should be documented, including that an RN assessed the resident and that the physician and family were notified. Facility policy on documentation required licensed staff to document all assessments, observations, and services provided in a complete, accurate, and timely manner, which was not followed in this case.