Failure of Governing Body to Align Policies With CMS Requirements for CPR Certification and Hyperglycemia Management
Penalty
Summary
The governing body failed to implement and align facility policies with Centers for Medicare & Medicaid Services (CMS) requirements, resulting in deficiencies related to CPR/BLS certification and diabetes management. Review of the facility’s governing body policy showed it was responsible for establishing and implementing policies for management and operation of the facility. However, the facility’s CPR policy only required a designated CPR team per shift (including at least one nurse, one LPN/LVN, and two CNAs with CPR/BLS certification) and did not include the CMS requirement that all clinical staff maintain current CPR certification through a provider with hands-on practice and in-person skills assessment. The facility reported having 47 nurse aides actively employed but was unable to provide evidence that any of them had CPR/BLS certification. The Medical Director confirmed that all healthcare providers employed by the facility were required to have CPR/BLS certification, demonstrating a discrepancy between practice, policy, and federal requirements. The governing body also failed to ensure that the facility’s diabetes clinical protocol provided clear direction to nursing staff on when to notify providers of hyperglycemia in the absence of specific physician orders. The diabetes policy listed possible physician-ordered interventions but did not specify notification parameters for elevated blood glucose levels. One resident with coronary artery disease and diabetes had a care plan instructing staff to monitor, document, and report signs and symptoms of hyperglycemia as needed, and an order for scheduled Humalog insulin with meals, but the physician’s orders did not include specific notification parameters. The resident’s blood sugar records showed multiple significantly elevated readings (ranging from 412 mg/dL to 533 mg/dL) without documentation that a provider was notified. The Medical Director stated his expectation that staff notify providers of out-of-range blood sugars greater than 400–450 mg/dL when parameters are not specified, and acknowledged that, because the facility policy did not define notification requirements and some physician orders lacked parameters, nursing staff would be unaware of general or specific notification requirements. The Nursing Home Administrator and DON acknowledged that the governing body failed to implement policies aligned with CMS requirements.
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