F0600

J

Failure to Assess Change in Condition and Evaluate for Hyperglycemia in Diabetic Resident

Salina, Kansas Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess and respond to a resident’s significant change in condition, resulting in neglect. The resident had diagnoses including diabetes mellitus with circulatory complications, dementia with severe cognitive impairment, hyperlipidemia, and a cognitive communication deficit, and resided on a secure unit. Her care plan identified her as at risk for hyperglycemia and directed staff to observe, document, and report signs and symptoms such as increased thirst, frequent urination, fatigue, and other indicators. Laboratory data showed an elevated HbA1c placing her at risk for diabetes, and the MAR included an order for PRN blood glucose monitoring with instructions to notify the provider if blood sugar was below 70 mg/dL or above 400 mg/dL.

In the days leading up to the event, documentation showed a decline in the resident’s functional status and intake that was not fully assessed. On one day, EMR task documentation lacked information on the amount of food consumed at breakfast and lunch, noted that she required staff assistance for eating and transfers, and showed she did not ambulate or required total staff assistance for ambulation, with no fluid intake documented. The following day, documentation again lacked food intake for breakfast and lunch, showed she required extensive assistance from two staff for transfers and ambulation, and still lacked fluid intake documentation. A health status note recorded that she had excessive weakness, could no longer ambulate independently or with assistance, and required two staff to pivot her from chair to wheelchair, but the EMR did not contain a complete set of vital signs or any blood glucose value associated with this change.

Later that same day, staff faxed the physician reporting that the resident had shakes, was more sleepy, not as awake as usual, and had frequent urination, and requested an antibiotic for a presumed UTI, noting unsuccessful attempts to obtain a urine specimen, including straight catheterization, though the EMR lacked documentation of these attempts. The physician ordered Macrobid, and a health status note documented administration of the first dose and continued weakness and cognitive decline, with the resident non-verbal and requiring staff to feed her. Again, the EMR lacked a complete set of vital signs and a blood glucose measurement despite documentation that vital signs were within normal limits. Early the next morning, staff reported the resident’s foot was cold and colorless; the nurse found it pale, cold, and non-blanchable, notified the on-call physician, and the resident was sent to the emergency department. In the ED, she was obtunded, with a point-of-care glucose reading “HI” and a laboratory glucose of 1020 mg/dL, along with a sodium level of 158 mEq/L and urine showing very high glucose but negative for bacteria and nitrites. Interviews with facility staff revealed that they believed the resident had a UTI, did not obtain or document complete vital signs, did not perform blood glucose checks, and did not consider hyperglycemia or dehydration as potential causes of her symptoms, despite her diagnosis and risk factors. The facility’s own Acute Condition Changes Protocol required comprehensive assessment and data collection, including vital signs and evaluation of possible causes, which were not carried out. This failure to assess and respond to the resident’s change in condition, including failure to consider and evaluate for hyperglycemia or dehydration, was determined to be neglect and placed the resident in immediate jeopardy.

Removal Plan

• Upon change of condition of any resident, Smoky Hill Nurses will complete a Change of Condition Form and notify the resident physician immediately.
• Any resident with a diabetes diagnosis will be assessed for hypo/hyperglycemia and labs as ordered by the physician.
• Nursing staff will be in-serviced on hypo/hyperglycemia and other conditions (frequent urination, lethargy, weakness, inability to ambulate, inability to feed self) as associated with diabetes.
• All residents with diabetes will be assessed for signs and symptoms of dehydration or hypo/hyperglycemia or any other changes associated with diabetes.
• The facility will monitor changes in condition 7 days a week and 5 days a week for 3 weeks.