F0658

D

Failure to Assess and Treat Hypoglycemia and Burns After Unwitnessed Fall

Amesbury, Massachusetts Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

Nursing staff failed to follow professional standards and physician orders for hypoglycemia management for a resident with diabetes who was found on the floor after an unwitnessed fall. The facility’s hypoglycemia policy and protocol required staff to recognize signs and symptoms of hypoglycemia, obtain a fingerstick blood glucose, and administer carbohydrates or IM glucagon for blood glucose levels under 70 mg/dL, followed by physician notification. The resident had active physician orders to administer 15–20 g of carbohydrates and reassess every 15 minutes if blood glucose was less than or equal to 70 mg/dL, to check blood glucose every 15 minutes until EMS arrival if unresponsive with blood glucose less than 70 mg/dL, and to administer 1 mg IM glucagon if unable or unwilling to swallow. Despite these orders, when the resident was found on the floor, slow to respond, with facial droop and inability to hold up the right arm, nursing staff did not obtain a fingerstick blood glucose or initiate the hypoglycemia protocol.

The resident, admitted in 2017 with diagnoses including dementia, chronic embolism and thrombosis of the lower extremities, diabetes, and a chronic right calf ulcer, was discovered at approximately 3:30 p.m. lying on the floor on the right side, leaning against a baseboard heater. The unit manager observed stroke-like symptoms, including facial droop and right arm weakness, and contacted the nurse educator, who was informed of stroke-like symptoms and stable vital signs. Neither the unit manager nor the nurse educator considered or requested a blood glucose check at that time, despite knowledge that the resident was diabetic and that hypoglycemia symptoms can mimic stroke. EMS arrived about 20 minutes later, obtained a fingerstick blood glucose of 24 mg/dL, and administered oral glucose and 1 mg IM glucose, after which the resident became more alert and responsive. Facility documentation, including the MAR, contained no evidence that nursing staff had checked the resident’s blood glucose or provided hypoglycemia treatment prior to EMS arrival.

Nursing staff also failed to assess and provide first aid for potential burn injuries after the resident was found lying against the baseboard heater. Facility burn first-aid policy required assessment and first aid to relieve pain and prevent infection. The unit manager recognized that the heater was very hot, could not keep her hand between the resident and the heater for more than a few seconds, and acknowledged the resident was at risk for a burn. After moving the resident off the floor and back to bed with assistance from CNAs, the unit manager noted a reddened area on the outside of the upper right arm that she believed was a burn but did not administer first aid or assess the resident’s back for additional injuries. Subsequent hospital documentation identified a large burn with skin sloughing on the back and right arm and deep partial thickness second- and third-degree burns to the back and upper right arm from contact with the baseboard radiator.