F0580

J

Failure to Notify Physician of Significant Change in Diabetic Resident’s Condition

New Bern, North Carolina Survey Completed on 02-06-2026

Penalty

Fine: $24,850

Summary

The deficiency involves the facility’s failure to notify the physician of significant changes in a resident’s condition and to obtain appropriate medical orders for monitoring and treatment. The resident had a history of Type 2 diabetes, epilepsy, schizophrenia, schizoaffective disorder, hypertension, kidney disease, prior metabolic encephalopathy, feeding difficulties, and dysphagia, and was a full code. On 1/14/26, the resident’s blood glucose was critically elevated at 466–496, and the on‑call provider ordered a one‑time dose of Novolog insulin, a recheck in one hour, and placement in the acute book for PCP follow‑up with instructions to notify if glucose remained greater than 450. The recheck that evening was 386, but there were no further documented blood glucose checks or additional orders addressing blood sugars or abnormal labs from 1/14/26 through discharge.

On 1/20/26, a nurse aide observed the resident sounding like she was getting a cold, with a deeper voice, dark circles and sunken eyes, and increased sleepiness, though the resident could still drink independently with a straw and assist with turning. On 1/21/26, a day‑shift nurse aide noted a significant change from the resident’s prior baseline: the resident remained sleepy all day, did not eat breakfast, lunch, or supper (only one bite at lunch), did not converse as usual, appeared darker in color, and could not pull fluid through a straw, requiring the aide to provide about one cup of fluids by sips. The aide reported to the nurse that the resident had not eaten breakfast or lunch and that she did not feel well. However, there was no documentation that the physician was notified of these changes, and no nursing progress notes on 1/21/26 reflected physician notification of a change in condition.

On 1/21/26, the assigned nurse assessed the resident for a bad cough and coarse lung sounds, believed a respiratory issue was present, and contacted the NP only about the cough, obtaining an order for a chest x‑ray. The nurse did not obtain a blood glucose level, did not take full vital signs beyond a temperature of 98.5, and did not communicate the resident’s poor oral intake, altered responsiveness, or prior critical blood sugar to the provider. Subsequent nurses on the evening and night shifts were informed that the resident was not eating and that a chest x‑ray was ordered, but they did not obtain vital signs or blood glucose checks, and they did not notify or consult the physician about the resident’s diminished responsiveness and need for total assistance with turning. In the early morning hours of 1/22/26, a nurse aide found the resident extremely warm with labored breathing; the nurse then obtained abnormal vital signs, including a temperature of 104.6°F, hypotension, tachycardia, and low oxygen saturation, and EMS was called. EMS documented a blood sugar reading of “high,” and the hospital ED documented the resident as obtunded, severely dehydrated, with a blood glucose of 882 and multiple abnormal labs. The surveyors determined that the facility failed to notify the physician of all observed changes in condition on 1/21/26 and failed to consult regarding whether additional diagnostic tests, monitoring (including blood glucose, oxygen saturation, and vital signs), or treatment were needed, leading to the cited deficiency.

Immediate jeopardy was determined to have begun on 1/21/26 when staff were aware that the resident had eaten only one bite in three consecutive meals, was not pulling up fluid through a straw, was not responding to staff per her baseline, and required total assistance to turn in bed and was no longer talking, without physician notification of these changes or consultation for further orders. The facility’s failure to notify the physician regarding all changes in condition and to obtain appropriate monitoring and treatment orders for the resident’s evolving symptoms on and after 1/21/26 constituted the core noncompliance identified by the surveyors.

Removal Plan

• Provide one-to-one education to NA #1 on the importance of communicating changes in condition timely to the charge nurse.
• Hold an ad hoc Quality Assurance Performance Improvement (QAPI) meeting including the Medical Director, Administrator, DON, Social Worker to address the breakdown in the nurse-to-provider notification process related to resident change in condition.