Failure to Implement Endocrinologist Recommendations for Complex Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement consultant physician recommendations for a resident with multiple complex medical conditions. The resident had diagnoses including diabetes, history of sepsis, resistance to multiple antimicrobial drugs, dementia, and Stage IV chronic kidney disease, with documented memory impairment on a recent Minimum Data Set assessment. A physician ordered an endocrinology evaluation, and a nurse practitioner endocrinologist subsequently assessed the resident and documented diabetes with hyperglycemia and neuropathy and Stage IV chronic kidney disease. The endocrinologist recommended specific laboratory tests, including blood work to assess blood sugar levels and thyroid function, and also recommended a nephrology consultation. Clinical record review showed no evidence that the recommended lab tests were ordered or completed, and no evidence that a nephrology consultation was ordered. In an interview, the Administrator confirmed that the endocrinologist’s recommendations had not been acted upon or addressed by the resident’s attending physician. This failure to follow through on the consultant endocrinologist’s recommendations for labs and a nephrology consult for a resident with serious comorbidities formed the basis of the cited deficiency under 42 CFR 483.25 (Quality of Care) and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services, and was noted as previously cited on 7/3/25.
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