F0684

E

Failure to Monitor Diabetes Control and Timely Address Recurrent Diarrhea

Palm Desert, California Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and the residents’ clinical needs for two residents. For one resident with type 2 diabetes mellitus and severe cognitive impairment, the record showed an elevated HgbA1C of 10.5% from a lab drawn in mid-February 2025, with a care plan problem of hyperglycemia and poor glycemic control. Physician orders included Lantus at bedtime and Humalog per sliding scale before meals and at bedtime. The MAR from early January through early February 2026 showed multiple blood glucose readings above 200 mg/dL with Humalog administered per sliding scale on multiple occasions. However, there was no evidence that the resident’s blood sugar control was evaluated through repeat HgbA1C testing after February 2025, nor that the frequent elevated blood sugars and repeated use of short-acting insulin were reported to the physician for possible adjustment of diabetic medications.

During interview and concurrent record review, the DON confirmed that the last HgbA1C for this resident was in February 2025 and that the resident did not have a standing order for routine HgbA1C monitoring, despite the facility’s diabetes clinical protocol stating that A1C should be monitored on admission (if no recent result is available) and every six months thereafter for residents receiving insulin who are well controlled, with frequency adjusted based on glucose control. The protocol also stated that if short-acting insulin must be administered frequently, the provider should consider initiating or adjusting intermediate- or long-acting insulin, and that providers will order desired glucose targets, monitoring regimens, and parameters for reporting information related to blood sugar management. The DON stated that the resident’s blood sugar should have been evaluated and referred to the physician if there was a need to adjust diabetic medications, but this was not done.

For another resident admitted with diagnoses including metabolic encephalopathy and sepsis, bowel continence documentation from mid- to late January 2026 showed multiple episodes of diarrhea recorded on numerous days and at various times. Despite these repeated episodes of loose stools beginning on January 17, 2026, there was no documented evidence that the episodes were addressed or that the physician was notified until a progress note on January 26, 2026, when the resident was documented as having nausea, vomiting, and diarrhea, multiple episodes of vomiting and diarrhea, fatigue, and mild abdominal tenderness. At that time, the physician ordered contact isolation and stool sample collection to rule out norovirus and C. difficile, and subsequent lab results on January 28, 2026, were positive for C. diff toxin. In interview, the DON acknowledged that the resident’s multiple episodes of loose stools starting January 17, 2026, were not addressed or referred to the physician within 72 hours, contrary to the facility’s “Change in a Resident’s Condition or Status” policy, which requires prompt notification of the physician for significant changes in a resident’s condition that will not normally resolve without intervention.