F0684

K

Failure to Assess and Notify Providers for Abnormal Blood Glucose Levels

Canonsburg, Pennsylvania Survey Completed on 04-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents with diabetes received treatment and care in accordance with professional standards of practice and physician orders related to capillary blood glucose (CBG) monitoring and response. Surveyors found that the facility did not have policies for management of diabetes, hypoglycemia, or hyperglycemia available when requested, despite the facility assessment indicating it provides care for residents diagnosed with diabetes. The existing “Episodic and Narrative Documentation” policy only indicated that a narrative entry would be made for physician notification, without specific guidance for hypo- or hyperglycemic events. Manufacturer instructions for the glucometer defined “Low” as less than 20 mg/dl and “High” as greater than 600 mg/dl, and prescribing information for long-acting insulin (Basaglar) described its onset and duration of action, underscoring the need for appropriate monitoring and timely response to abnormal blood glucose values.

For multiple residents with diabetes and other comorbidities such as chronic kidney disease, congestive heart failure, coronary artery disease, COPD, dementia, and end-stage renal disease, surveyors identified numerous CBG values that met or exceeded ordered parameters for provider notification or represented clinically significant hypo- or hyperglycemia, without documentation of physician notification, reassessment, or follow-up. Examples included residents with sliding-scale insulin orders specifying to notify the provider if blood glucose was under 70 mg/dl or over 400 mg/dl, yet blood sugars in the 400–500+ mg/dl range and lows in the 50–60 mg/dl range had no corresponding notes, rechecks, or documented provider contact. In some cases, residents had repeated elevated readings over several days, including meter readings of “HI” (over 600 mg/dl), with no documentation of notification or follow-up. Several insulin and blood sugar monitoring orders also lacked any parameters for provider notification, even as residents experienced significantly abnormal CBG values.

Specific residents cited included individuals admitted with diagnoses of diabetes and chronic kidney disease, CAD, CHF, dementia, COPD, CKD, ESRD, and heart failure. Their records showed repeated elevated CBG values such as 401–591 mg/dl and lows as low as 55–57 mg/dl without documented assessment for signs and symptoms of hypo- or hyperglycemia, without rechecks, and without documented physician notification as required by orders. In one instance, a resident left the facility for a leave of absence after a CBG of 495 mg/dl without reevaluation. Interviews with LPN staff revealed that they could verbally describe appropriate steps for managing blood sugars under 70 mg/dl or over 400 mg/dl, including rechecking, giving snacks or glucose, monitoring, and notifying the physician and supervisor, and documenting in the MAR and progress notes. However, the clinical records reviewed did not reflect that these actions and notifications were consistently carried out or documented for the abnormal CBG values identified, leading surveyors to determine that the facility failed to notify physicians of elevated or decreased CBG levels and failed to assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for 12 of 21 residents reviewed.

Plan Of Correction

The physician was notified for Residents R2,R4,R16,R33,R37,R46,R47,R56,R70, R80, R97 and R116 that their Capillary Blood Glucose levels were either greater than 400 or less than 70. The facility NP saw these residents to assess any impact from a Capillary Blood Glucose result not reported to the physician. For residents with current orders for Capillary Blood Sugar testing, results greater than 400 or less than 70 will be recorded, documented, and the MD/designee will be notified to issue further treatment orders as needed.

The DON/Designee began educating nursing staff, including contracted staff on the facility's new policy titled "Managing Hypo and Hyperglycemia." The DON/designee will educate new nursing staff to the facility before the start of their first shift. Licensed Nursing Staff will attend Directed In-Service with AAE Consulting Services Inc on May 5th, 2026 Titled F684 Quality of Care 483.25.

Licensed staff who do not attend the training in person on this date will have to watch the training provided prior to the start of their next shift. The DON/Designee will review all current diabetic residents in the facility with orders for Capillary Blood Sugar testing results during the daily clinical Morning Meeting M-F to verify that residents' Capillary Blood Sugar results were recorded, documented, and the MD/designee was notified. Saturday and Sunday results will be reviewed by the Nursing Supervisor for the same compliance.

The DON /Designee will complete audits for the compliance of the new policy Managing Hypo and Hyperglycemia for 10% of facility resident with orders for Blood Sugar testing for 4 weeks then monthly times 4

The facility NHA will query 5 random nurses 3 times a week for 4 weeks then weekly for 4 weeks and then monthly for 3 months to verify their knowledge of the protocols for Hypo/Hyperglycemic Management. Results of the audits will be reviewed during QAPI and frequency adjusted based on the results of the audits.

Removal Plan

• Report identified residents’ out-of-range finger stick blood sugar results to the Nurse Practitioner and have the NP evaluate the residents and update orders as indicated.
• Review and update Resident R16’s care plan to include a diabetes care plan.
• Conduct NP review/rounds on current residents who may be impacted by a diabetic emergency to verify appropriate orders are in place and update as indicated.
• Have the MDS nurse review current diabetic residents’ care plans to verify a diabetes care plan is in place and update as indicated.
• Create a facility policy titled “Managing Hypo and Hyperglycemia.”
• Provide education by DON/ADON to current nurses (including agency) on the hypo/hyperglycemia protocol; continue for staff not yet trained and all new hires; require completion prior to working a shift.
• Notify the Medical Director of the Immediate Jeopardy and that the NP is seeing all current diabetic residents.
• Hold an ad hoc QAPI meeting with the Medical Director to review and discuss the Immediate Jeopardy and the Immediate Plan of Correction.
• Implement daily review of all current diabetic residents’ FSBS results in weekday morning clinical meeting by DON/ADON and weekend review by nursing supervisor to verify FSBS is recorded/documented and MD/designee is notified; continue per the established audit schedule.
• Implement NHA competency checks by querying random nurses to verify knowledge of hypo/hyperglycemia management protocols per the established audit schedule.
• Review audit results in QAPI and adjust audit frequency based on results.
• Complete a root cause analysis identifying lack of a formalized hypo/hyperglycemia management policy as the cause.