Failure to Notify Physician of Critically High Blood Glucose and Perform Ordered Monitoring
Summary
The deficiency involves the facility’s failure to immediately notify the physician when a resident’s blood glucose (BG) levels exceeded ordered parameters and to consistently perform ordered BG monitoring. An older female resident with type 2 DM with hyperglycemia, early-onset Alzheimer’s disease, hypertension, and a vesicointestinal fistula was admitted with physician orders for BG monitoring before meals and at bedtime, with instructions to notify the provider if BG was less than 60 mg/dL or greater than 400 mg/dL. Review of the order summary and admitting physician orders confirmed these parameters. However, record review showed multiple BG readings well above 400 mg/dL over several days without documented physician notification, and there was no evidence that bedtime BG checks were performed as ordered. Specifically, the resident’s record showed BG values of 512 mg/dL on one day, 482 mg/dL on the next day, 459 mg/dL on a later day, and 492 mg/dL on another day, all documented without any corresponding evidence that the physician was notified, despite the explicit order to notify for BG values greater than 400 mg/dL. The medication administration record and BG logs also showed no documented nighttime BG checks, even though the orders required monitoring before meals and at bedtime. The resident’s care plan identified insulin therapy and BG monitoring with goals for BG within normal limits and interventions including monitoring, documenting, and reporting adverse effects of insulin therapy and following hypo/hyperglycemia protocols, but the actual documentation did not reflect adherence to these monitoring and notification requirements. Interviews with facility staff and external PACE providers further described inconsistent communication and incomplete implementation of ordered treatments. The NP from PACE stated she was not notified that the resident’s BG had been over 400 mg/dL and that, upon later review, insulin and BG monitoring orders had been provided but were not implemented as ordered by the facility. A PACE RN reported that he was notified of elevated BG and gave instructions for additional sliding scale insulin and close monitoring, and that long-acting insulin should have continued, but there was no documentation in the facility record to support these communications or new orders. Facility nurses described elevated BG readings in the 400–500 mg/dL range, sometimes unreadable on the glucometer, ongoing use of sliding scale insulin, delays or gaps in admission order processing, and uncertainty about whether antibiotics ordered were administered. The resident was ultimately transferred to the hospital with hyperglycemia and UTI and was admitted to the ICU for DKA and septic shock. The facility’s own policy on blood glucose monitoring required following physician notification parameters when results were outside ordered ranges, but the documented practice for this resident did not meet those requirements, leading surveyors to identify an Immediate Jeopardy situation related to failure to notify the physician of out-of-parameter BG results and failure to carry out ordered BG monitoring. Additional interviews with leadership and other staff highlighted that medication reconciliation and admission review processes were inconsistent and that there was no standardized daily review of medications or BG monitoring for accuracy and completeness. The ADON and DON acknowledged that medication pass audits were not done daily, that there was no consistent daily process to review medications, and that communication with external providers such as PACE was often inconsistent. The DON and Medical Director described expectations that urgent situations be evaluated immediately and that orders be implemented without delay, but also acknowledged that residents with worsening conditions were sometimes transferred to the hospital rather than having earlier interventions. The MDS nurse stated that she did not recall seeing documentation regarding antibiotic therapy or BG monitoring for this resident and that follow-up on such treatments depended on nursing processes. The PACE NP later stated that prophylactic antibiotics and insulin management had been ordered but not administered, and that the resident’s decline, including DKA and sepsis, was attributed in part to missed medications and lack of timely intervention. These documented failures in BG monitoring, physician notification, and implementation of ordered treatments formed the basis of the cited deficiency.
Removal Plan
- Conduct mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtain verbal and written confirmation of understanding; implement ongoing competency checks; ensure policies are readily available from the CNO/ACNO; incorporate training and written competencies for new hires upon hire.
- Review Resident #2’s current hospitalization status with the hospital and confirm ICU admission for DKA and septic shock; confirm resident did not return to the facility.
- Hold nurse meetings with all nursing staff who cared for Resident #2 to review specific failures (missing bedtime BG checks, failure to notify provider of BG >400, failure to administer continuous glucose monitoring device, failure to communicate about unavailable supplies).
- Provide mandatory re-education for all licensed nursing staff (RNs/LPNs) emphasizing: obtaining BG readings exactly as ordered; immediate provider notification when results are outside parameters; immediate notification to physician/CNO/ACNO when ordered supplies/equipment are unavailable; and clarifying unclear or unimplementable orders prior to implementation.
- Establish a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes in condition, out-of-parameter lab/glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-service RNs/LVNs on the protocol.
- Implement a redundant notification system requiring that when any BG result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time, person contacted, and response received; in-service RNs/LVNs on the system.
- Conduct a facility-wide review to identify residents at risk for similar failures related to physician notification, BG monitoring, or implementation of orders.
- Review all current residents to identify those with active BG monitoring orders.
- Complete a comprehensive chart audit of residents with BG monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely documented provider notification; report identified issues to physicians and obtain clarifying or new orders as needed; initiate continued daily monitoring by CNO/ACNO/nurse manager.
- Conduct a Root Cause Analysis (RCA) including staff interviews and fishbone analysis to identify underlying causes of the IJ event.
- Revise the Blood Glucose Monitoring Policy to require immediate physician notification for out-of-parameter BG results and to require documentation of the exact time of the out-of-parameter result, exact time of provider notification, name of person contacted, and provider response or orders received; educate staff on the revised policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify Providers and Families of Resident Changes in Condition: Staff did not document or complete required notifications for multiple residents after new skin tears, wound care needs, refusal of ADL care, and falls/accidents. Records showed an LPN and RN assessed and dressed wounds, but provider and family notification was not documented; one resident repeatedly refused bathing without physician or RP notification, and another resident’s falls were not consistently reported to family as required.
The facility failed to promptly notify resident representatives when two residents fell and had changes in condition. One resident with dementia and anxiety fell in the TV room and sustained a chin laceration, and another resident with schizophrenia, anxiety, and an unsteady gait had a witnessed fall in her room with a left upper arm skin tear. In both cases, the provider was notified and treatment orders were received, but the records did not document representative notification at the time of the events.
Failure to notify a resident’s DPOA of a new medication order. A resident with DM, vascular dementia, and moderately impaired cognition was newly ordered fluconazole, but the EMR lacked documentation that the DPOA was informed. The DPOA reported she had not been notified, and staff stated they were expected to call the family or representative about new meds or treatments and document the notification.
Failure to notify the MD and resident representative of a significant BiPAP setting change. A resident with CHF, rheumatic heart disease with mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema had a physician order for BiPAP 28/5 with FiO2 40%. The RT changed the settings to 25/5 because the machine could not tolerate higher settings, but did not notify the MD, nursing supervisor, or representative, and did not document the change.
Failure to promptly notify the physician of a significant change in condition for a resident with acute respiratory failure and HF. The resident refused a newly ordered oral diuretic and continued to have low O2 sats despite an increased O2 order, but the record showed no documented physician notification. The resident was later found unresponsive.
A facility failed to notify the provider about missed meds for three residents and a change in condition for one resident. One resident with COPD missed 34 Duoneb treatments, another resident missed 12 hydromorphone doses and 10 pregabalin doses and later showed withdrawal symptoms, and a third resident missed 9 oxycodone doses because meds were out of supply. The record lacked evidence the provider was notified of the missed doses, and the resident with withdrawal symptoms also lacked timely provider notification of the change in condition.
Failure to Notify Providers and Families of Resident Changes in Condition
Penalty
Summary
The facility failed to notify residents’ physicians and/or resident representatives of changes in condition for multiple residents, including new or worsening skin issues, refusal of ADL care, and accidents. The report identified failures involving Resident #2, Resident #37, Resident #28, Resident #11, and Resident #30. The deficiency was based on observation, interview, and record review showing that required notifications were not documented after these events occurred. Resident #37 was observed with a bandage on the lower right forearm, and records showed wound care orders for skin tears to the arms and right wrist. The resident’s progress notes from 6/1/2026 through 8/10/2026 contained no documentation of notification to a provider or the resident representative regarding the wounds or dressings. Staff A, RN, the wound care nurse, stated she assessed the resident, found wounds on both forearms with dressings already in place, cleaned and redressed them, entered wound care orders, but did not write a progress note or contact a provider or the family. The physician stated he could not recall receiving a call about the wound, and the DON stated the wound care nurse was expected to notify family and a provider if a new or worsening wound was identified. Resident #2 had a skin tear to the left lateral ankle/left lower leg with a wound care order entered as a verbal order from Physician #2. The resident was observed with a gauze bordered dressing on the left lower extremity, and the resident stated the wound nurse had changed the dressing and said she would return later. Review of progress notes showed no documentation of the skin tear, no notification to family or provider, and no treatment orders documented in the notes. Resident #11 refused bathing on multiple occasions, but the record contained no documentation that the physician or resident representative was notified of the refusals. Resident #28 had a new skin tear to the right wrist that was bleeding and was assessed and dressed by nursing staff, but there was no documentation that the provider was notified. Resident #30 had a history of falls and skin tears, and the DON stated the family should have been notified for the resident’s falls; the report cited a failure to notify the resident’s family of the accident/change in condition as required.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to ensure residents’ representatives were immediately notified when residents fell or had a change in condition. The facility policy, revised in February 2021, stated that the resident, attending physician, and resident representative are to be promptly notified of changes in the resident’s medical or mental condition and/or status. Survey review found that this did not occur for 2 of 4 residents reviewed for changes in condition. Resident #7, who had diagnoses including major depressive disorder, dementia, and anxiety, fell while walking out of the doorway in the TV room and sustained a laceration to the chin. The provider was notified and orders were given for steri-strips and monitoring, but the record did not document that the resident’s representative was notified at the time of the fall. Resident #57, who had diagnoses including schizophrenia, anxiety, and unsteady gait, had a witnessed fall in her room and sustained a skin tear to the left upper arm. The provider and DON were notified and treatment orders were received, but the record did not document that the resident’s representative was notified at the time of the event.
Failure to Notify Legal Representative of New Medication Order
Penalty
Summary
The facility failed to ensure Resident 39’s legal representative was notified of a new medication order. Resident 39 had diagnoses of diabetes mellitus and vascular dementia, with a BIMS score of 8 indicating moderately impaired cognition. He was documented as alert to self, dependent on staff for toileting and personal hygiene, and newly admitted to hospice with vascular dementia. His care plan instructed staff to notify his durable power of attorney of any changes related to him. On 07/30/2026, the provider saw Resident 39 and ordered fluconazole 100 mg daily for 14 days, but the progress note did not document that the DPOA was notified. On 08/03/2026, the DPOA stated she had not been informed of the new fluconazole order and reported the facility had not always notified her of new orders. Staff interviews confirmed that the nurse should have called the family or representative about new medications or treatments and documented the notification in the EMR, and that it was expected for the nurse to notify the family or representative of all new orders and document it in the EMR.
Failure to Notify Physician and Representative of BiPAP Setting Change
Penalty
Summary
The facility failed to immediately consult the resident’s physician when a treatment was significantly altered. Resident #1 was admitted with congestive heart failure, rheumatic heart disease complicated by mitral stenosis, chronic respiratory failure with hypercapnia, and acute pulmonary edema. The Minimum Data Set documented moderately impaired cognition, and the resident required continuous oxygen therapy and non-invasive mechanical ventilation (BiPAP). A physician’s order dated 07/15/2026 specified BiPAP settings of IPAP 28 and EPAP 5, with FiO2 40 percent at bedtime as tolerated and removed in the morning. On 07/16/2026, the Director of Respiratory Therapy changed the BiPAP settings from 28/5 to 25/5 because the machine could not tolerate settings over 25/5. The Director of Respiratory Therapy stated they did not review the physician’s order before ordering the BiPAP machine, did not notify the physician, nursing supervisor, or the resident’s representative of the change, and did not document the events in the medical record. The resident’s representative stated they were not notified of the change, the RN stated they were not informed that the settings had been changed, and the Medical Doctor stated they were not aware the BiPAP machine had not been delivered on 07/15/2026 or that the ordered settings had been changed.
Failure to Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to promptly notify the attending physician of a significant change in condition for Resident 107. The resident was admitted with diagnoses including acute respiratory failure and heart failure, and a quarterly MDS dated May 26, 2026, showed the resident was cognitively intact with a BIMS score of 15. On June 30, 2026, the resident was seen for weight gain and increasing oxygen requirement. The physician documented that the resident refused an intramuscular diuretic that morning, continued to refuse hospitalization or a change in code status, and had new orders to increase oxygen to 5.0 L/min and later increase oral furosemide to 80 mg twice daily. Later that day, the resident refused the newly ordered oral furosemide 80 mg. The clinical record showed repeated low oxygen saturation readings despite the increased oxygen order, including values of 87% to 89% on June 30 and 88% on July 1 while on nasal cannula oxygen. The record contained no documented evidence that the facility notified the physician of the resident’s refusal of the oral furosemide or of the continued low oxygen saturation after the revised oxygen order was implemented. A progress note on July 1, 2026, at 5:30 AM documented that Resident 107 was found unresponsive. During an interview on July 31, 2026, the Nursing Home Administrator and DON reviewed the findings and confirmed there was no documented evidence that the physician had been notified after the resident refused the newly prescribed oral furosemide or continued to have oxygen saturation levels of 87% to 89%.
Failure to Notify Provider of Missed Medications and Change in Condition
Penalty
Summary
The facility failed to notify the provider of missed medications for three residents reviewed for medication errors. R4, who was cognitively intact and had diagnoses including vascular parkinsonism, heart failure, and COPD, had an order for Duoneb nebulizer treatments three times daily for COPD. The July MAR showed 34 missed Duoneb treatments from 7/9/26 through 7/20/26, and progress notes documented that staff noted no supply for each missed treatment. R4 also requested a PRN nebulizer treatment for shortness of breath on 7/16/26, but the record lacked evidence that the provider was notified of the missed treatments. R20, who was cognitively intact and had diagnoses including COPD, type 2 diabetes with diabetic neuropathy, anxiety, and moderate protein-calorie malnutrition, had long-term orders for hydromorphone 4 mg BID and pregabalin 100 mg TID for chronic pain. The July 2026 MAR showed 12 missed hydromorphone doses and 10 missed pregabalin doses because the medications were out of supply, and progress notes documented no supply for each missed dose. The record lacked evidence that the provider was notified of the missed doses. R20 later had documented complaints of not feeling well, loss of appetite, SOB, skin crawling, difficulty sleeping, and signs and symptoms of withdrawal, and the on-call NP stated the nurse had requested only refill orders and had not reported the missed doses or symptoms. R22, who had moderate cognitive impairment and diagnoses including COPD, spondylosis, and chronic pain syndrome, had an order for oxycodone 5 mg BID for chronic pain syndrome. The July MAR showed 9 missed oxycodone doses from 7/18/26 through 7/22/26 because there was no supply, and progress notes documented no supply for each missed dose. The record lacked evidence that the provider was notified of the missed oxycodone doses. The facility’s Change in Condition policy stated that the facility would inform the resident, consult with the physician, and notify the resident representative when a change occurred, and the DON stated nurses were expected to notify the provider in SBAR form for missed medications and changes in condition.
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