F0711

D

Failure to Manage and Monitor Diabetes and Document Physician Oversight

Glendale, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure by the attending MD, NP, and licensed nursing staff to adequately supervise and manage the medical care of a resident with Type 2 DM, including failure to follow and/or appropriately modify GACH discharge orders, failure to document clinical reasoning and treatment decisions, and failure to communicate effectively among providers. The resident had a care plan for "Risk for Unstable Blood Glucose Level" that instructed staff to check blood glucose if it was below 70 mg/dL and to administer glucagon and call 911 if the resident was unconscious or without vital signs, and to observe for signs and symptoms of high blood glucose and report them to the physician. However, the care plan did not address how licensed nurses would measure the resident’s blood glucose levels to determine if they were below 70 mg/dL. GACH discharge orders dated 1/11/2026 directed renewal of fingerstick blood sugar checks AC & HS, with additional PRN checks and parameters to notify the physician for blood sugars greater than 250 mg/dL or less than 70 mg/dL and to implement a hypoglycemia protocol.

Upon readmission on 1/11/2026 with diagnoses including Type 2 DM and sepsis, the facility’s Physician Order Reports from 1/11/2026 through 1/31/2026 did not include orders for AC & HS fingerstick blood sugar monitoring or monitoring for hyperglycemia, but only an order to monitor for signs and symptoms of hypoglycemia three times a day. A nursing progress note on 1/11/2026 documented that the attending MD was notified of the readmission and that physician orders were “verified and carried out,” but there was no documentation that the nurse clarified with the MD whether blood sugar monitoring should continue as per GACH discharge instructions. In interview, the RN stated that the MD verbally declined to renew the AC & HS fingerstick orders and said he would assess the resident the next day, but this decision and rationale were not documented in the medical record. There was no progress note by the MD on or after 1/12/2026 documenting an assessment, plan, or justification for not monitoring blood sugars, and the NP’s H&Ps and progress note did not document how blood sugar monitoring should be performed or any coordination with the MD regarding the decision not to follow the GACH blood sugar monitoring orders.

From admission on 12/11/2025 through 2/8/2026, only three provider visits were documented, all authored by the NP (two H&Ps and one progress note), with no progress notes by the MD. The NP reported that she was managing the resident’s care with the MD, knew the resident had Type 2 DM, and that the DM was being monitored with random blood work (CBC, BMP), but stated the resident should have had AC & HS fingerstick monitoring and that she was unaware the GACH readmission orders for AC & HS blood sugar checks were not renewed. On 2/5/2026, the NP ordered 1 liter of NS IV for poor oral intake and hyponatremia, but she was not informed whether this was carried out, was not informed of a STAT fasting blood glucose result of 351 mg/dL, and was not informed that the MD later ordered D5W IV instead of NS. The DON confirmed that on 2/6/2026 the MD ordered 3 liters of D5W at 60 cc/hr after being notified of the high fasting blood glucose, and that licensed nurses did not clarify this order despite the elevated glucose level or question the absence of fingerstick monitoring. The MD acknowledged ordering D5W for nutrition and comfort despite knowing the resident was hyperglycemic and did not document this plan or rationale in the record.

On 2/8/2026, nursing documentation and SBAR showed a significant change in condition: the resident was non-verbal, with shallow respirations, oxygen saturation of 87%, respiratory rate of 33, temperature of 100.7°F, heart rate of 133 bpm, and a blood glucose of 463 mg/dL. Oxygen at 15 L via non-rebreather was initiated, improving saturation to 95%, and 911 was called. The paramedic run report documented arrival at 4:16 PM, altered level of consciousness, non-responsiveness to name, sinus tachycardia at 130 bpm, respiratory rate of 32 with labored breathing, temperature of 101°F, and discontinuation of D5W due to a blood glucose of 530 mg/dL. GACH ED records indicated the resident was admitted for altered level of consciousness, fever, and hyperglycemia, and noted that the facility had treated a blood sugar of 350 mg/dL with dextrose. ED testing showed blood sugars of 530 mg/dL and 434 mg/dL and high urine glucose. The NP stated she was unaware of the resident’s hyperglycemic state, the administration of D5W, or the change in condition and hospitalization. The Medical Director stated that keeping a resident in a hyperglycemic state and infusing D5W in that context would not benefit the resident and that residents with Type 1 or 2 DM need AC & HS blood glucose monitoring. Facility policies on Physician Services and Physician Orders required medical evaluation, review of orders and plan of care at each required visit, appropriate progress notes, and clear physician orders, but the record lacked documentation of assessments, clinical reasoning, treatment decisions, and communication among the MD, NP, and licensed staff regarding the resident’s DM management, change in condition, critical lab results, and ordered treatments.