Failure to Implement Antibiotic and Diabetes Management Orders Resulting in ICU Admission
Summary
The deficiency involves the facility’s failure to assess a newly admitted resident prior to admission and to identify and implement critical physician orders related to antibiotic therapy and blood glucose management. The resident was an adult female with diagnoses including a vesicointestinal fistula, hypertension, type 2 diabetes mellitus with hyperglycemia, and early-onset Alzheimer’s disease, and was cognitively intact with a BIMS score of 14. Admitting physician orders included long-acting insulin (Semglee), sliding-scale insulin (NovoLOG), use of a FreeStyle Libre 2 continuous glucose monitoring (CGM) sensor, blood glucose checks before meals and at bedtime with provider notification if values were <60 or >400 mg/dL, and prophylactic antibiotics (Ciprofloxacin and Metronidazole) following recent surgery and hospitalization. The facility’s records from admission through several days afterward showed no evidence that the antibiotic orders were transcribed or administered, and no baseline blood glucose assessment was completed upon admission. From admission through the days leading up to the resident’s hospitalization, multiple blood glucose readings were documented in the 459–512 mg/dL range, which exceeded the ordered notification parameter of >400 mg/dL. Despite these critically elevated readings, there was no documentation that the physician or PACE providers were notified as required by the resident’s orders and the facility’s blood glucose monitoring policy. The medication administration record and blood glucose logs also showed no documented nighttime blood glucose checks, even though orders specified monitoring before meals and at bedtime. Although a FreeStyle Libre 2 CGM sensor was documented as applied on one date, interviews with nursing staff and leadership revealed that staff were unfamiliar with consistent use of the Libre system, had not been trained, and did not routinely utilize CGM devices, instead relying on glucometer readings. Interviews with PACE nurses and the PACE NP indicated that orders for antibiotics, probiotics, insulin, and the CGM device had been sent upon the resident’s discharge from the hospital, but these orders were not implemented as written by the facility. PACE staff reported that the resident had multiple blood glucose readings outside ordered parameters without physician notification, that nighttime blood glucose checks were not obtained as ordered, and that the continuous glucose monitoring system was not implemented. Facility staff, including LVNs and RNs involved in the admission and subsequent care, acknowledged delays and discrepancies in medication reconciliation, uncertainty about whether antibiotics were ordered or administered, lack of training and supplies for the Libre device, and inconsistent communication with external providers. The DON and ADON further acknowledged that medication reconciliation was not completed for this resident upon admission, that hospital records were not consistently reviewed prior to implementing care, and that there was no standardized process to ensure implementation of continuous glucose monitoring orders. As a result of these failures, the resident was later transferred to the hospital, where she was admitted to the ICU with diagnoses of diabetic ketoacidosis and septic shock, and treated for hyperglycemia and infection, including E. coli and yeast identified in cultures. An Immediate Jeopardy situation was identified by surveyors related to these failures in assessment, medication reconciliation, implementation of physician orders for antibiotics and blood glucose management, and required physician notification for out-of-parameter glucose readings. The facility’s own policies on physician orders and blood glucose monitoring required that orders be valid, clear, and implemented safely, and that physicians be notified when glucose results were outside ordered parameters, but these policies were not followed in the resident’s case. Interviews with the DON, ADON, Medical Director, and MDS staff confirmed that admission assessments were not consistently completed prior to residents’ arrival, that not all admissions received pre-admission review of hospital records, and that oversight of blood glucose monitoring and continuous glucose monitoring devices was inconsistent and lacked a standardized process. These combined actions and inactions led to the cited deficiency for failure to provide needed care and services in accordance with the resident’s preferences, goals, and professional standards of practice.
Removal Plan
- Conducted mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; staff provided verbal and written confirmation of understanding.
- Implemented ongoing competency checks for staff; ensured policies are readily available from the CNO/ACNO; required new hires to complete training and written competencies upon hire.
- Reviewed the resident’s hospitalization status with the hospital and confirmed ICU admission for DKA and septic shock; confirmed the resident did not return to the facility.
- Held nurse meetings with all nursing staff who cared for the resident to review specific failures in blood glucose monitoring, provider notification, administration of the CGM device, and communication of unavailable supplies.
- Provided mandatory re-education for all licensed nursing staff on the Blood Glucose Monitoring Policy and Physician Notification requirements, including obtaining BG readings as ordered, immediate provider notification for out-of-parameter results, notifying leadership/providers when supplies/equipment are unavailable, and clarifying unclear/unimplementable orders prior to implementation.
- Established 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-serviced RNs/LVNs on the protocol.
- Implemented 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-serviced RNs/LVNs on the system.
- Conducted a comprehensive review to identify other residents at risk for failures in physician notification, blood glucose monitoring, or implementation of physician orders.
- Reviewed all residents to identify those with active blood glucose monitoring orders.
- Completed chart audits of residents with BG monitoring orders to verify monitoring as ordered, identify out-of-parameter results, and confirm timely documented provider notification; reported identified issues to physicians and obtained clarifying/new orders; instituted continued daily monitoring by CNO/ACNO/nurse manager.
- Reviewed all residents to identify those with orders for continuous monitoring devices or specialized medical equipment.
- Physically verified that all residents with ordered devices/equipment had the devices in place and functioning as ordered.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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