F0684

G

Failure to Follow Diabetic Orders, Notify of Changes in Condition, and Complete Post-Fall Assessments

Danville, Illinois Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to implement diabetic care and follow physician orders, to notify providers and family of changes in condition, and to complete required post-fall assessments for several residents. One resident with long-standing type 1 diabetes was admitted after hospitalization for dehydration and hyperglycemia, with hospital discharge orders for Novolog insulin per sliding scale three times daily, insulin glargine 12 units every evening, and frequent blood glucose monitoring. These hospital orders, including the Novolog sliding scale and instructions to monitor blood glucose regularly, were not fully transcribed into the facility’s physician orders or MAR, and a baseline care plan addressing diabetes and the use of a continuous glucose monitor was not created. Blood glucose monitoring three times daily before meals was not consistently documented until several days after admission, and some blood glucose readings were missing. Staff obtained blood pressures on the arm where the continuous glucose monitor was located, despite the device manual indicating that pressure on the sensor can affect readings, and there was no order or care plan instruction to avoid that arm.

For this same resident, nursing notes show that insulin glargine was held on the evening of admission due to vomiting and lack of food, without notifying the provider. The resident refused bolus tube feedings on subsequent days, and these refusals were not reported to a provider. Nursing documentation shows episodes of very high blood glucose readings, including “over high/over 400” on the continuous glucose monitor, with additional insulin doses given per immediate orders, but there were gaps in blood glucose checks, including a period where the continuous glucose monitor was not working and the resident refused finger-stick checks. Staff did not consistently notify the physician when the continuous glucose monitor failed or when the resident refused blood glucose checks. The physician later stated that hospital orders for Novolog sliding scale three times daily should have been continued, that staff should have reported the device malfunction and refusals, and confirmed that the lack of appropriate monitoring and insulin administration contributed to the resident’s rehospitalization for diabetic ketoacidosis, with an emergency room glucose level of 1194 mg/dL.

Another resident with diabetes had orders for insulin glargine and short-acting insulin (insulin aspart/Novolog) but had numerous doses of both long-acting and short-acting insulin held over multiple months without documentation that the physician was notified. The MAR shows that long-acting insulin glargine was not administered on multiple evenings, and short-acting insulin aspart/Novolog scheduled three times daily was held many times even when blood glucose was greater than 110, despite there being no active order after readmission to hold the short-acting insulin for blood glucose less than 110. The physician later stated this was the first time he became aware that staff were holding long-acting insulin, that he does not order parameters to hold long-acting insulin, and that staff should report any time insulin is held outside ordered parameters. The DON confirmed there was no documentation of provider notification for the held insulin doses and that there was no active order to hold the short-acting insulin.

The deficiency also includes failure to timely notify a physician and family of a change in condition following a fall, resulting in delayed treatment of a compression fracture. One resident with severe cognitive impairment experienced an unwitnessed fall and was found sitting on the bathroom floor. Initial assessment documented no injuries, and the resident was returned to the wheelchair. Over the next days, the resident developed increasing lower back pain, became tearful and crying, and required PRN pain medication. Nursing documentation shows that pain was rated as high as 8 on a 1–10 scale, and an LPN obtained orders for a lumbosacral x-ray and PRN ibuprofen. However, there is no documentation that the new onset and increased back pain following the fall was reported to a provider prior to the day the x-ray was ordered, and no documentation that the resident’s family was notified of the pain or the new orders until the day the x-ray results were received and the resident was transferred to the hospital. The family member reported being told only that the resident had fallen and then later that the resident was going to the hospital, without interim updates about pain or diagnostic testing.

Post-fall assessment deficiencies were also identified. For the resident with the unwitnessed fall, neurological assessments were documented at multiple time points after the fall, but all entries contained the same set of vital signs recorded at the initial time, indicating that vital signs were not actually reassessed and documented as required. The RN acknowledged that neurological checks should be completed every 15 minutes for one hour, every 30 minutes for two hours, then every four hours for 24 hours with vital signs each time, and confirmed that all documented checks showed the same vital signs from the initial assessment. Another resident with diabetes, a history of subdural hematoma and subarachnoid hemorrhage, and current anticoagulant therapy (Eliquis) experienced a witnessed fall while attempting to self-transfer. There was no documentation that blood glucose was checked at the time of the fall or that neurological assessments were initiated, despite the resident’s diabetes and prior brain bleed. The LPN involved stated that blood glucose was not checked because the resident was alert and did not appear hypoglycemic, and that neurological assessments were not started because the fall was witnessed. The DON later stated that neurological assessments should be initiated for any unwitnessed falls, but the documentation shows that required neurological and blood glucose assessments were not completed as outlined in facility policies and care plans.