F0684

J

Failure to Monitor Diabetes and Act on Critical Labs Leading to Resident’s Collapse

El Paso, Texas Survey Completed on 03-12-2026

Penalty

Fine: $124,950

Summary

The deficiency involves the facility’s failure to provide care and services in accordance with professional standards for a resident with multiple comorbidities, including Diabetes Mellitus, coronary artery disease, hypertension, peripheral vascular disease, and a recent left below-knee amputation. The resident was admitted from an acute hospital with multiple oral hypoglycemic medications and later had orders for insulin glargine and insulin lispro with sliding scale coverage. Despite this, there was no documentation that blood glucose monitoring was performed from admission until the day of the acute event, even though the care plan called for diabetes medication as ordered, monitoring for side effects and effectiveness, and education on glucose monitoring. A family member reported that they were concerned that staff were not checking the resident’s blood sugar and brought the resident’s home glucometer to the facility, where they obtained readings in the 400s and 500s.

The facility also failed to act on critical laboratory results and to promptly notify the physician or nurse practitioner of significant changes in the resident’s condition. On one date, the physician ordered a CBC with differential, comprehensive metabolic panel, lipase, and amylase, along with abdominal imaging, in response to new complaints of abdominal pain, diarrhea, and low appetite. The labs were collected the following morning, and the lab report later showed a critical WBC of 30.9 K/uL flagged as “CRITICAL HIGH” with a red octagon. A lab monitoring sheet showed the labs were collected, and a witness statement from an LVN indicated that when the laboratory called with the critical WBC result at 6:06 p.m., he answered the phone, wrote the result on a piece of paper, and immediately handed it to the LVN assigned to the resident, emphasizing the critical nature of the result and advising her to verify it in the portal. Video footage corroborated that the LVN received a piece of paper after the lab call. However, there was no documentation that the critical WBC result was reported to the physician or NP, and the lab result remained marked as pending review in the electronic record.

In the days leading up to the resident’s decline, the resident repeatedly complained of abdominal pain, nausea, vomiting, diarrhea, and poor intake. Nursing notes documented multiple administrations of PRN hydrocodone for abdominal pain with high pain scores, and a family member reported that the resident had been complaining of stomach pain, throwing up, not eating, and having diarrhea for approximately two weeks. The family stated they had reported these symptoms to an LVN, who allegedly attributed them to dementia and did not assess the resident. On the day of the acute event, the family again found the resident weak, complaining of abdominal pain and nausea, and used their own glucometer to obtain blood glucose readings in the 400s. Nursing staff then notified the physician, who ordered blood glucose checks before meals and at bedtime, a moderate-dose sliding scale, and insulin doses including lispro and later Lantus. The nurse administered insulin but did not document the exact times of blood glucose checks or insulin administration. Subsequent blood glucose readings remained elevated above 500 mg/dL, and the resident became clammy, lethargic, and then unresponsive with a heart rate of 194. Multiple attempts were reportedly made to contact the physician and NP by phone and group text without response. The DON was informed that the resident’s condition was deteriorating, with fixed pupils and increasing lethargy, and instructed that the resident be sent to the ER. EMS was activated, and upon EMS arrival the resident was already unresponsive; she was transported to the hospital, where she was treated for altered mental status, severe acidosis, hypoxia, and hyperkalemia and was pronounced dead later that day. The facility’s failures included not monitoring blood glucose despite diabetes and multiple hypoglycemic medications, not documenting and acting on critical lab results, and not immediately notifying the physician of the resident’s worsening condition and unresponsiveness.