F0684

J

Failure to Monitor and Treat Diabetes and Acute Status Changes Leading to Resident Death

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

Penalty

Fine: $24,850

Summary

The deficiency involves the facility’s failure to comprehensively assess, monitor, and treat a resident’s diabetes and to provide acute monitoring and assessment when the resident later developed respiratory symptoms in the context of uncontrolled hyperglycemia. The resident had multiple diagnoses including type 2 diabetes, chronic kidney disease, intellectual disability, schizoaffective disorder, epilepsy, hypertension, and a history of feeding difficulties and dysphagia. A HgbA1C drawn on 10/14/25 was 8.1% (above the lab’s normal range of ≤5.7%), but there was no documented plan to address this elevated result. The consultant pharmacist notified the NP on 11/5/25, suggesting initiation of Metformin or Jardiance, but the NP initialed “no change” on 11/20/25 without documenting a rationale or creating a treatment plan, and no diabetic medications were ordered. The resident’s care plan, reviewed on 12/15/25, contained a problem related to diabetes-associated fatigue but did not include any interventions for blood sugar monitoring or diabetes management.

On 12/18/25, the NP documented a regulatory visit and follow-up of chronic conditions, noting the resident’s diabetes as diet controlled based on an older HgbA1C of 6.5 from 9/1/24 and did not reference the elevated 10/14/25 HgbA1C of 8.1. On 1/5/26, a different NP saw the resident for chronic issues but addressed only hyperlipidemia, hypertension, and vitamin D deficiency, and did not review or plan for the resident’s diabetes, despite the elevated HgbA1C from October. A CMP drawn on 1/13/26 and reported on 1/14/26 showed a critically high serum glucose of 466, elevated creatinine, low potassium and chloride, high CO2, and a reduced estimated GFR. A nurse notified the on-call provider via the triage system, reporting the critical glucose, a finger-stick blood sugar (FSBS) of 496, stable vital signs, and the resident’s complaint of feeling sleepy all day, and requested insulin orders. The provider ordered a one-time dose of Novolog 10 units SQ, a recheck of glucose in one hour, and notification if the result remained above 450. The insulin was administered and a repeat FSBS was documented at 386, but no further blood sugar checks or additional orders addressing the abnormal labs were documented after 1/14/26.

A progress note later received from the NP, dated for a service date of 1/15/26, stated that the resident was seen for an acute visit for elevated blood glucose, that labs were at baseline except for glucose, and that the resident was asymptomatic with no signs of infection or hyperglycemia. The NP documented that staff were encouraged to monitor for signs and symptoms of hyperglycemia and infection, to take FSBS, and to notify the PCP for status changes, and referenced risks such as diabetic ketoacidosis, hyperosmolar hyperglycemic state, blindness, kidney disease, heart attack, further decline, and rehospitalization if left untreated and unmonitored. However, no orders were actually written for FSBS monitoring or repeat HgbA1C, and no further blood sugar checks were documented from 1/14/26 through discharge. On 1/19/26, the resident received a COVID vaccine and had a recorded temperature of 97.6; this was the last documented vital sign before the acute decline. Over 1/19/26 and 1/20/26, nursing and NA staff reported the resident appeared at baseline.

On the evening of 1/20/26, an NA noted the resident reported feeling like she was getting a cold, had a deeper voice, dark circles and sunken eyes, and was sleepy but still able to drink independently with a straw; the NA believed she informed a nurse but could not recall whom. On 1/21/26, multiple staff observed significant changes: the resident did not eat three consecutive meals (except for one bite at lunch), was unusually sleepy, did not converse at her baseline, and required assistance with drinking, with one NA unable to get her to pull fluid through a straw. A nurse caring for her that morning noted a bad cough and coarse breath sounds, difficulty administering medications in the morning due to somnolence, and only minimal intake at lunch. This nurse requested a chest x-ray from an NP, obtained an order, and verified it with the mobile x-ray company, but did not obtain a full set of vital signs or check the resident’s blood sugar, documenting only a temperature she recalled as 98.5 and citing a very busy day. Another nurse manager recalled being told the resident did not seem herself and knew a chest x-ray was ordered but did not perform an assessment. There were no nursing progress notes for 1/21/26 documenting vital signs or FSBS, and interviews with four nurses confirmed that no complete sets of vital signs or blood sugar levels were obtained despite the resident’s decreased intake, increased sleepiness, cough, and functional decline.

In the early morning of 1/22/26, EMS was dispatched for the resident, and paramedics found a blood sugar reading of “high.” The resident was transported to the ED, where she was noted to be obtunded and dehydrated, with a glucose of 882, a temperature of 41.7°C (107.06°F), and other lab abnormalities. She coded at 6:53 AM and expired after unsuccessful resuscitation attempts. The survey identified that immediate jeopardy began on 1/15/26 when the facility failed to ensure ongoing monitoring and initiation of a treatment plan for the resident’s critically elevated blood glucose following the 1/14/26 lab result, in the context of a previously elevated HgbA1C and subsequent development of respiratory symptoms without appropriate acute monitoring, assessment, and treatment.