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 MD of Worsening Wound: A resident with multiple comorbidities and a pressure injury had a right gluteal abrasion that progressively worsened from an open wound to a stage IV ulcer with drainage, odor, slough, and exposed tissue. Staff documented the decline in skin assessments and notes, but there was no reproducible evidence that the MD was notified when the wound first deteriorated. The wound later became infected and required hospital transfer for surgical debridement.
A resident with severe cognitive impairment and a history of falls, weakness, malnutrition, and difficulty walking was found on the floor and later developed persistent right hip, thigh, and RLE pain with inability to bear weight. PT and OT notes documented worsening pain and limited mobility, but progress notes did not show notification to the MD or NP. The resident was later sent to the hospital, where imaging showed a displaced right femoral neck fracture.
Failure to notify legal representative of significant change in condition: A resident with dysphagia, CKD, and moderate cognitive impairment had a vasovagal episode in the shower and later vomited, but the family was not immediately informed. Staff notified the PA and monitored the resident, yet the legal representative said the first notice from the facility was after the resident had died. The facility policy required notification of the resident or legal representative for significant changes such as vomiting or vital sign changes.
Failure to Notify Provider of Elevated Heart Rate: A resident with CVA, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm after prior readings were consistently lower, but the record did not show that the MD or NP was notified. The unit manager and NP both stated they would expect notification of the abnormal HR and further assessment of the resident's status.
A resident had an unwitnessed fall, but the physician and resident representative were not notified until the next morning. The facility’s policy required prompt assessment and notification after a fall, and the resident had capacity to understand and make decisions. An LVN said the delay occurred because the resident did not show a change in condition, while an RN stated the nurse should have notified the physician and representative immediately after assessing the resident.
A facility failed to notify family representatives about missed morning medications for eight residents. MARs showed blank administration entries for the medication pass, and Progress Notes did not document family notification. Interviews with family members and the POA confirmed they were not told about the medication omissions, while the DON stated notifying families of medication errors is standard practice and should be documented.
Failure to Notify Physician of Worsening Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician when a resident’s right gluteal wound deteriorated. The resident was admitted with diagnoses including major depressive disorder, atrial fibrillation, obesity, osteoarthritis, and a pressure ulcer of the left heel, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with bed mobility and was dependent on staff for transfers. The care plan and MDS documented pressure injury risk, pressure-reducing devices, turning and repositioning, weekly skin assessments, and reporting abnormal findings to the PCP. The resident’s right gluteal abrasion was first identified after a hospital return and was treated with ordered wound care. The wound then worsened over time, with skin issue reports documenting deterioration, increasing size, non-healing tissue, pain, drainage, odor, slough, and exposed adipose tissue. A nurse note on 3/23 documented increased drainage, slough, foul odor, exposed adipose tissue, and that the resident needed to see a doctor and may need antibiotics, but the facility could not provide reproducible evidence that the physician was notified or what the physician ordered in response. Staff statements reflected that notes were placed for the physician to see, but documentation of actual notification was not available. The wound continued to decline after the 3/23 note, with later reports showing worsening odor, purulent drainage, bleeding, and rapid enlargement. The wound nurse practitioner later documented that the wound had significantly deteriorated and required debridement, and the resident was ultimately hospitalized for surgical debridement. Hospital records documented a stage IV pressure ulcer with infection and sepsis/shock, and the wound culture grew multiple organisms. The survey findings also included staff and physician interviews indicating that the physician had no documentation of notification during the period when the wound was worsening and that earlier notification could have allowed more aggressive treatment.
Failure to Notify Provider of New Right Hip Pain and Inability to Bear Weight
Penalty
Summary
The facility failed to follow its policy for notification of a change in resident condition by not notifying the physician and/or nurse practitioner when a resident developed new right lower extremity pain and inability to bear weight. The resident had a history that included weakness, unspecified fall, hypotension, severe protein calorie malnutrition, major depressive disorder, cognitive communication deficit, metabolic encephalopathy, and difficulty walking, and had a BIMS score of 4/15 indicating severe impairment. After the resident was found on the floor on the right side next to the bed with lacerations, redness to both knees, a laceration to the right ankle, and redness to the right hip, the resident initially denied pain. Subsequent PT and OT documentation repeatedly recorded pain in the right hip, thigh, and right lower extremity, with pain increasing with movement, sitting, standing, bending, and weight bearing. PT notes documented that the resident required walker support, took only a few small steps with max assist due to pain, later became unable to ambulate because of severe right lower extremity pain, and was unable to put weight on the leg and had difficulty standing. OT notes also documented aching right lower extremity pain that limited lower body ADLs and functional mobility tasks. The progress notes did not document notification to the doctor or nurse practitioner about the pain or the changes in the resident's right lower extremity. When the resident was later sent to the hospital at the family’s request, the nurse practitioner and ADON were made aware, and the resident was transported by ambulance. The hospital record documented right hip pain, tenderness to palpation and with range of motion of the right hip, and x-ray findings of a superolateral displaced right femoral neck fracture. The hospital history noted the resident may have fallen two weeks earlier, and the daughter reported the last time she saw the resident walking was four weeks earlier. Staff interviews indicated the APRN and NP were not notified of the pain or inability to bear weight, and both stated they would have assessed the resident and likely ordered an x-ray if they had been informed.
Failure to Notify Legal Representative of Significant Change in Condition
Penalty
Summary
The facility failed to immediately notify the resident's legal representative of a significant change in condition for one resident reviewed for notification of changes. The resident was admitted with pneumonitis due to inhalation of food and vomit, dysphagia, and stage 3 chronic kidney disease. The Minimum Data Set dated 05/06/2026 documented that the resident could sometimes be understood, could sometimes understand others, and had moderate cognitive impairment. On 05/14/2026, the resident experienced a vasovagal episode while in the shower and later had episodes of vomiting, including brown-colored emesis. Progress notes documented that staff notified the PA of the resident's condition, assessed the resident, and monitored vital signs. The facility policy titled Notification Policy required the attending physician or designee and the resident or resident's legal representative or interested family member to be notified by the nurse of a significant change in condition, including vomiting, change in mentation, change in vital signs, or respiratory distress. There was no documented evidence that Family Member #2 was immediately notified of the vasovagal episode or the vomiting. Family Member #2 stated they were not informed of these events and first learned from the facility when told the resident had passed away at 12:07 PM. Staff interviews confirmed that family notification was expected for significant changes, and the PA stated they were contacted about the vasovagal episode, the vomiting, and later the resident's death.
Failure to Notify Provider of Elevated Heart Rate
Penalty
Summary
The facility failed to notify the resident's physician or nurse practitioner when the resident had a change in vital signs that could have required physician intervention. Resident #2 was admitted in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. Review of the resident's heart rates from January 2026 through 3/4/26 showed rates ranging from 57 to 89 beats per minute, with no documented heart rate over 100 beats per minute during that period. On 3/5/26 at 9:00 AM, the resident's March 2026 MAR documented a heart rate of 122 beats per minute. The medical record did not show that the physician or NP was notified of this increase. During interview, the unit manager stated she would expect the physician to be notified because the rate was far outside the resident's usual range and said she would notify the doctor and recheck the heart rate after medication. The NP stated he would expect to be notified about a heart rate of 122 because he would want to know whether the resident was symptomatic, whether the respiratory rate was elevated, or whether other issues such as sepsis, pain, or positioning were contributing.
Delayed Notification After Resident Fall
Penalty
Summary
The facility failed to notify Resident 4’s physician and resident representative of an unwitnessed fall in a timely manner. The facility’s Fall Prevention and Response policy stated that after a fall, a licensed nurse shall promptly respond, assess the resident, and notify the physician and resident representative. Resident 4 was admitted to the facility and had an H&P showing the resident had the capacity to understand and make decisions. Resident 4’s SBAR Fall Report documented a fall on 5/3/26 at 2330 hours, but the physician and resident representative were not notified until 5/4/26 at 0744 hours. LVN 1 stated the resident was monitored closely after the fall and that notification was delayed until the following morning because the resident did not exhibit a change in condition. RN 1 verified the fall occurred and stated the licensed nurse should notify the physician and resident representative immediately after assessing the resident rather than waiting until the next morning. The DON was informed and acknowledged the findings.
Failure to Notify Families of Missed Morning Medications
Penalty
Summary
The facility failed to notify resident family representatives of missed administration of significant morning medications for eight residents. Review of the Medication Administration Records for R1, R2, R3, R4, R5, R6, R7, and R8 showed blank boxes without nurses’ initials to indicate the medications were administered on 5/10/26 during morning medication pass. The residents’ Progress Notes did not document that family representatives were notified of the medication omission errors. Interviews confirmed the lack of notification. On 5/21/26, R8’s POA stated the facility did not notify her that R8 missed medications on Mother’s Day. On the same day, R1’s family member stated she was not contacted about the missed medications, and R2’s family member stated no one called or told him there were problems with his father receiving medications. The Interim DON stated it is standard practice for family representatives to be notified of medication errors, that floor nurses are expected to contact families, and that the notification should be documented in the resident’s medical record. The facility policy on Physician-Family Notification-Change in Condition states the facility will inform the resident, consult the physician or authorized designee, and if known, notify the legal representative or interested family member.
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