F0658

E

Failure to Follow and Document Physician and Hospice Orders for Fluids, Diabetes Management, Foot Care, and Wound Care

Las Cruces, New Mexico Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures by facility staff to follow and document physician and hospice orders, resulting in services that did not meet professional standards of quality. For one resident with end stage renal disease on hemodialysis, a Hemodialysis Communication Record dated 01/29/26 contained an order for a 1500 ml fluid restriction. This order was not entered into the resident’s medical record, and a CNA stated the resident was not on a fluid restriction. The DON confirmed that the fluid restriction order had been received on 01/29/26, was not entered into the medical record, and that the resident’s fluids were not restricted as ordered.

Another resident with a diagnosis of diabetes mellitus had convalescent care orders dated 10/15/25 to check blood sugar levels before meals and at bedtime. Insulin orders for Humulin R before meals and at bedtime were discontinued on 10/17/25 after the resident refused insulin, blood sugar checks, and blood work, but the resident continued on Insulin Glargine 20 units twice daily. The care plan, revised 10/21/25, directed staff to monitor blood glucose levels as ordered and to monitor for signs and symptoms of high and low blood sugar and report abnormal findings. However, medication administration records from October 2025 through February 2026 showed no documentation of blood sugar levels or refusals, and no documentation of monitoring for symptoms of high or low blood sugar. Vital sign records showed intermittent blood sugar readings only on specific dates, and progress notes from 10/16/25 to 02/02/26 did not document monitoring for signs or symptoms of high or low blood sugars. An LPN stated there was no current order in the medical record to monitor blood sugar levels, that the monitoring order was inadvertently discontinued with the Humulin R order, and that he did not routinely monitor diabetic residents for signs and symptoms of high or low blood sugar. The DON confirmed staff did not document monitoring for signs and symptoms, and the physician and medical director both stated that blood sugar monitoring should have continued.

A third resident was observed to have overgrown, yellow, thick, and cracked toenails and reported that their toenails had not been cut in a long time. The DON confirmed the toenails were overgrown and had not been cut. A progress note from a medical appointment dated 10/28/25 documented painful mycotic toenails and a follow-up appointment in two months for routine foot care, but the medical record contained no documentation that a follow-up appointment was scheduled. The DON confirmed that a two‑month follow-up for routine foot care had been ordered and that no follow-up appointment was scheduled.

For another resident with a pressure wound on the sacrococcygeal area, a physician’s order dated 01/14/26 directed wound care with normal saline or wound cleanser, calcium alginate, and optifoam every Monday, Wednesday, and Friday. Hospice documentation dated 01/28/26 provided new wound care orders: discontinue the previous sacrococcygeal wound care orders, cleanse with wound cleanser, apply calcium alginate and crushed Flagyl, then cover with carboflex and optifoam, with wound care to be completed daily and as needed. These hospice wound care orders were not entered into the resident’s medical record. The January 2026 Treatment Administration Record showed no wound care documented on 01/29/26. The wound care nurse confirmed that the hospice order from 01/28/26 was not entered, that the 01/14/26 order remained in the record, and that there was no documentation that the provider was notified of the new hospice orders. The DON confirmed that hospice had provided new daily wound care orders, that there was no documentation of provider notification, that the medical record still contained the 01/14/26 order, and that the resident did not receive wound care on 01/29/26.