F0684

K

Failure to Implement Antibiotic and Diabetes Management Orders Resulting in ICU Admission

El Paso, Texas Survey Completed on 03-13-2026

Penalty

Fine: $53,825

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.