F0684

G

Failure to Monitor Acute Change in Condition, Skin Integrity, and Diabetes Management

Broadview Heights, Ohio Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and care plan interventions for monitoring and treating acute changes in condition and skin integrity, as well as failure to timely treat a new diagnosis of type 2 diabetes. One resident with a history of type 2 diabetes mellitus with neuropathy, obstructive and reflux uropathy, prior osteomyelitis, and documented risk for bladder incontinence and skin breakdown reported blood in his urine in the evening. A nurse practitioner was contacted and ordered a urinalysis and urine culture and sensitivity, but there was no documentation that the resident’s urine was assessed or described, and no evidence that vital signs, temperature, or mental status were monitored from the time of the complaint through several subsequent days. The medical record showed no evaluation by the resident’s NP or PA after the report of hematuria, and no documented monitoring for urinary status or change in condition during this period, despite facility policy requiring assessment and documentation of changes such as altered urination, confusion, or lethargy.

The same resident had multiple risk factors for skin breakdown and was care planned for weekly head‑to‑toe skin assessments and treatment documentation for any skin issues. A Braden assessment identified mild risk, and a prior diabetic heel ulcer had been documented as healed and discharged from wound care. A skin tear on the right middle knuckle was documented and ordered to be monitored every shift, and a weekly skin check on one date showed no new problems. However, a wound culture for Candida auris was later obtained from an open area on the resident’s arm due to scratching and picking, without clear documentation of the wound’s location or ongoing treatment. A weekly skin check was marked as completed on the treatment record, but there was no corresponding assessment form in the record. When the resident was transferred to the hospital after an acute decline, hospital documentation identified an unstageable pressure injury on the right lower buttock and non‑pressure ulcers on both feet that were present on admission, as well as multiple skin tears on the bilateral upper extremities, none of which had been documented on the transfer form or in the facility’s recent assessments.

On the morning of the acute event, staff found the resident in bed, humming, with involuntary right arm shaking, confusion, and repeated inappropriate responses. Vital signs showed hypotension and bradycardia, and a blood glucose of 59, but no temperature or oxygen saturation was recorded. A subsequent note described the resident as pale, cool, clammy, stuporous, and unable to make eye contact or answer questions appropriately, and EMS was called. EMS documented a blood glucose of 47, hypotension, bradycardia, and altered mental status, and the resident was transported to the emergency department. In the ED, the resident was found to be hypothermic with a core temperature of 86.4°F, hypotensive, and bradycardic, and was diagnosed with altered mental status, UTI, sepsis, hypothermia, and hypotension. A urine culture collected at the facility showed Proteus mirabilis >100,000 CFU/mL with ESBL production and resistance to ciprofloxacin; an order for oral ciprofloxacin had been started based on lab results, but the organism was resistant. The resident was admitted to the MICU with sepsis and septic shock, and multiple wounds were documented as present on admission.

A second deficiency involved another resident with type 2 diabetes mellitus without complications and other neurologic and muscular diagnoses. This resident’s hemoglobin A1c was elevated, and a NP was notified that the resident refused metformin, stating a preference to try diet control first. The dietitian recommended use of a FreeStyle Libre 2 continuous glucose monitoring sensor because the resident did not want finger sticks, and the NP ordered the Libre sensor to assist with pre‑meal glucose checks three times daily. Review of the medical record from the time of the order through several months later showed no evidence that blood sugars were checked, and the MAR repeatedly showed the Libre sensor order not completed, with notations such as the sensor being on order or not available, and in some instances no reason documented at all. The resident later reported being told she was diabetic but receiving no diabetes education and having no blood sugar checks performed, and she stated she did not know what she was supposed to do about her diabetes.