F0835

E

Failure to Ensure Provider Notification of Abnormal Blood Glucose Levels

Canonsburg, Pennsylvania Survey Completed on 04-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the failure of the Nursing Home Administrator (NHA) and the Director of Nursing (DON) to effectively manage the facility to ensure provider notification of residents’ changes in condition, specifically related to capillary blood glucose (CBG) levels. Review of the NHA’s job description showed that the NHA is responsible for overall leadership, management, and operation of the facility, including ensuring high-quality care and regulatory compliance. Review of the DON’s job description showed that the DON is responsible for overall clinical leadership and management of nursing services, including ensuring resident-centered care and compliance with Pennsylvania Department of Health and CMS regulations.

Surveyors determined that the facility failed to ensure that physicians or other advanced practice providers were notified when residents’ CBG levels were outside the parameters set in the physicians’ orders. This failure affected 12 of 21 residents reviewed (R2, R4, R16, R33, R37, R46, R47, R56, R70, R80, R97, and R116). During an interview, the NHA and current DON confirmed that facility administration did not effectively manage the facility to ensure provider notification of changes in condition. This failure resulted in an Immediate Jeopardy situation for those residents, and was cited under 28 Pa. Code 201.14(a), 201.18(b)(1)(3)(e)(1), and 211.12(d)(1)(2)(3)(5).

Plan Of Correction

Nursing Home Administrator (NHA) and the Director of Nursing (DON) will effectively manage the facility to ensure provider notification of resident changes in condition by ongoing auditing and staff education on the requirement to notify the physician of abnormal blood sugar results to prevent a negative outcome to occurs Weekly reports by both the Administrator and the DON will be presented to the Greenery Center for Rehab and Nursing governing body to ensure the delivery of high-quality short-term rehabilitation and long-term care services while maintaining compliance with all federal, state (Pennsylvania), and local regulations. The Nursing Supervisor will be educated by the DON/Designee on the importance of notifying a physician of abnormal blood sugar results This education will be ongoing for licensed nursing staff. The DON/Designee will complete weekly ongoing audit of 90% abnormal blood sugar results and physician notification to prevent any negative outcome from occurring.