Citations in Florida
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Florida.
Statistics for Florida (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Florida
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility. The facility did not ensure these rights were upheld as required.
Surveyors observed several containers of food in the walk-in cooler that were not labeled or dated, contrary to facility policy. The Dietary Manager confirmed that all food items should be labeled and dated when placed in the cooler, but this was not done for food from the breakfast meal.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified during the survey.
The facility did not consistently administer insulin and cardiovascular medications as ordered for several residents, and nursing staff failed to notify the physician or document appropriately when medications were withheld due to abnormal blood sugar or blood pressure readings. Nurses often relied on their own judgment without following established parameters or facility policy, resulting in missed doses and lack of timely communication with providers.
A resident's MDS assessment was not transmitted to CMS within the required 14 days after completion. The assessment, completed and marked as ready for submission, was not forwarded to the corporate office for review in a timely manner, resulting in a missed deadline for transmission.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, without proper justification documented.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
Two residents were found with topical medications stored openly at their bedsides without physician orders or documented assessment for self-administration. Staff and the DON confirmed that neither resident was authorized to self-administer medications, and facility policy requires locked storage unless specific criteria are met.
Two residents were found with various medications, including topical creams and nasal sprays, stored at their bedside over several days without physician orders for self-administration. These medications were not kept in locked compartments as required, and no documentation supported resident self-administration.
Surveyors found that the facility did not maintain a clean and safe environment for several residents, including cracked bathroom fixtures, stained walls, a persistently dirty refrigerator that a resident could not clean due to physical limitations, unclean personal items for a bedbound resident, and a wheelchair with exposed foam. Staff interviews confirmed that CNAs were responsible for daily cleaning, and facility leadership acknowledged the issues.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulations. Specific actions or omissions by facility staff led to this deficiency, but no further details about the residents involved or their medical conditions are provided in the report. The deficiency centers on the lack of adherence to protocols that protect resident autonomy in making decisions about their care and participation in research, as well as the formulation of advance directives.
Improper Food Labeling and Storage in Kitchen Cooler
Penalty
Summary
During a walk-through tour of the kitchen, several containers of food were observed in the walk-in cooler without identifying labels or dates. The Dietary Manager confirmed that all items placed in the cooler should be labeled and dated, and acknowledged that there were no identifying labels on food that had been placed in the walk-in cooler from the breakfast meal. Facility policy requires that all foods stored in the refrigerator or freezer be covered, labeled, and dated, but this procedure was not followed for the observed items.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not specify particular actions, inactions, or events, nor does it mention any specific residents or staff involved in the deficiency.
Failure to Administer Medications and Notify Physician per Standards
Penalty
Summary
The facility failed to administer insulin and cardiovascular medications according to professional standards of practice for multiple residents. For one resident with a history of diabetes, chronic kidney disease, and heart disease, insulin was not administered as ordered on two occasions, and there was no documentation of physician notification when the medication was held or when the resident experienced hypoglycemia. The nurse involved stated uncertainty about the reason for holding the insulin and did not notify the physician, despite the absence of parameters to hold the medication. Facility policy required physician notification when medications are held due to abnormal vital signs or test results, but this was not followed. Another resident with hypertension had their prescribed Lisinopril withheld on multiple occasions due to low blood pressure or hypotension, as documented in the medication administration record. Nursing staff reported using their own judgment to hold the medication and did not consistently notify the physician, sometimes leaving notes for the charge nurse or physician instead. The Director of Nursing acknowledged that nurses should notify the physician when medications are held, but there was inconsistency in how and when this was done, and the facility's policy required notification in such cases. A third resident with diabetes had insulin and metformin held on certain days, sometimes without following the specific parameters in the physician's orders. In one instance, insulin was held despite the blood sugar being above the threshold for administration, and the nurse attributed this to confusion with another order. The Director of Nursing and the physician confirmed that nurses should follow parameters and document accurately, but there was a lack of consistent communication and documentation when medications were withheld. Facility policies required accurate documentation and physician notification when medications were held, but these procedures were not consistently followed.
Failure to Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required 14 days after completion. Review of the electronic medical record showed that the annual MDS assessment for a resident was completed and marked as 'Production Batch' on 8/3/2025, indicating it was ready for submission. However, the assessment was not transmitted to CMS by the required deadline of 8/17/2025. Interviews with facility staff revealed that the process involved sending the completed MDS assessment to the corporate office for review before submission to CMS. The Care Plan Coordinator and the MDS Coordinator both confirmed that the assessment was not forwarded to the corporate office for initial review when completed, resulting in no validation report being received and the assessment not being transmitted on time. The delay in forwarding the assessment to the corporate office directly led to the failure to meet the CMS transmittal requirement.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Improper Bedside Storage of Medications Without Authorization
Penalty
Summary
Surveyors observed that two residents had medications, specifically Arnica cream and Vicks Vaporub, stored openly on their bedside tables in their rooms. These medications were accessible to the residents without any documented physician orders permitting self-administration, and there was no evidence that the residents had been assessed or approved by the facility's interdisciplinary team to self-administer medications. Staff interviews confirmed that neither resident had orders to self-administer, and that the facility's policy required medications to be stored in locked compartments unless a resident was specifically authorized and provided with a lock box for self-administration. Further review of facility policies indicated that bedside medication storage is only permitted with a prescriber's written order and after an assessment of the resident's ability to self-administer. Despite these requirements, both residents had medications at their bedsides without the necessary orders or assessments. Staff and the DON acknowledged that medications should not be left unattended at the bedside and confirmed that the observed practice was not in accordance with facility policy.
Failure to Securely Store Medications at Bedside
Penalty
Summary
Facility staff failed to ensure the safe and secure storage of medications for two residents, as required by professional standards. For one resident, multiple medications including medicated body powder, isopropyl alcohol, ointments, creams, and an ophthalmic solution were observed stored at the bedside table over several days, with no physician order for self-administration documented in the medical record. Similarly, another resident was found with allergy relief nasal sprays at their bedside on multiple occasions, also without any orders for self-administration or physician authorization for these medications. These observations were confirmed through direct inspection, review of the electronic medical record, and photographic evidence, indicating that medications were not stored in locked compartments as required.
Failure to Maintain Clean, Safe, and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, safe, and homelike environment in several resident rooms. In one occupied room, the bathroom toilet lid was cracked and the ceiling near the entryway had a brown, rust-like substance between the tiles. Another occupied room had brown stains and scratched paint on the wall. A small refrigerator in a resident's room contained a foul odor, spilled brown liquid, unfinished bottles of soda, and ice cream spilled throughout the freezer compartment; the resident confirmed the refrigerator had not been cleaned for a long time and was unable to clean it herself due to physical limitations. Multiple follow-up observations confirmed the refrigerator remained dirty over several days. A bedbound resident was observed with a pillow and board used to hold a cell phone, both of which had stains and organic particles that remained uncleaned over several days. Another resident's wheelchair had an armrest with exposed foam. During an interview, an LPN stated that CNAs were responsible for wiping surfaces daily and as needed. The facility's Administrator, Maintenance Director, and Housekeeping Account Manager acknowledged these issues during a tour.
Some of the Latest Corrective Actions taken by Facilities in Florida
- Educated Administrator and DON on responsibility to implement the Excessive Heat Emergency Plan and monitoring/notification procedures (K - F0835 - FL)
- Educated Administrator and DON on job descriptions emphasizing accountability for maintaining safe temperatures and resident comfort (K - F0835 - FL)
- Reviewed affected regulations and emergency-plan implementation during QAPI meeting (K - F0835 - FL)
- Delivered facility-wide abuse/neglect training with post-test verification (K - F0600 - FL)
- Implemented policy barring staff from work until reeducated on Abuse and Neglect policies (K - F0600 - FL)
- Administered written competency test covering notification procedures for rooms at or above 81 °F (K - F0600 - FL)
- Provided staff instruction on cool-zone locations and consequences of failing to report high temperatures (K - F0600 - FL)
- Educated maintenance staff on maintaining facility temperatures between 71 °F and 81 °F (K - F0584 - FL)
- Established procedure to activate the emergency plan immediately when an air-conditioning unit fails (K - F0584 - FL)
- Educated clinical staff on abuse/neglect issues related to resident assessment and care when temperatures exceed 81 °F (K - F0584 - FL)
Failure to Maintain Safe Temperatures During Air Conditioning Outage
Penalty
Summary
Facility administration failed to utilize its resources effectively and efficiently to maintain a safe and comfortable temperature for residents when multiple central air conditioning units broke down in several halls and common areas. Despite being aware of ongoing issues with the air conditioning units, as documented in resident council meeting minutes from January through April, administration did not implement immediate and effective measures to address the excessive heat. Residents repeatedly raised concerns about uncomfortable temperatures, and the administration acknowledged the problems but only noted that the concerns were being addressed, without evidence of timely or sufficient action. On multiple occasions, temperatures in residents' rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended comfort range. Several residents reported ongoing discomfort, difficulty sleeping, and feeling overheated for weeks, with some stating that the issue had persisted for months. The facility's temperature monitoring logs did not include resident rooms and were only conducted twice a month in common areas, failing to capture the actual conditions experienced by residents. The Director of Nursing confirmed that interventions to mitigate heat exposure, such as providing ice, water, and monitoring vital signs, were not implemented until after temperatures had already reached excessive levels. Interviews with residents and staff further revealed that the excessive heat was a persistent problem, with residents expressing that their complaints were not adequately addressed. The administration's approach relied on hallway temperature checks to trigger room checks, which proved insufficient. The lack of timely and comprehensive action to ensure a safe and comfortable environment for all residents created a likelihood of serious harm or death due to prolonged exposure to excessive heat, resulting in the determination of Immediate Jeopardy.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Took temperatures throughout the facility at multiple times and verified they were within the range of 71 to 81 degrees.
- Facility will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Completed education with the Administrator and Director of Nursing (DON) by the President of Clinical Operations regarding their responsibility to implement the facility excessive heat emergency plan related to broken air conditioning units.
- Education included the monitoring process and notification procedure to the Chief Executive Officer/Chief Nursing Officer and to ensure residents are provided with a clean, comfortable environment.
- Chief Nursing Officer educated the Administrator and DON on their job descriptions, emphasizing responsibility to ensure proper temperatures and a safe, comfortable environment.
- Reviewed the agenda and staff sign-in page for the Quality Assurance and Performance Improvement (QAPI) meeting, which included a review of the affected regulations and implementation of the facility's Excessive Heat Emergency Plan.
Failure to Maintain Safe and Comfortable Temperatures Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not taking immediate and appropriate actions to maintain safe and comfortable temperature levels when multiple central air conditioning units broke down in several halls and common areas. Despite the breakdown of the central air conditioning units in the 400, 500, and 700 halls, the facility did not implement its Emergency Preparedness Plan in a timely manner to ensure residents' comfort and minimize the risk of hyperthermia. Window air conditioning units were installed in some resident rooms, but there was no consistent monitoring of room temperatures to ensure they remained within a safe range. Residents repeatedly reported discomfort due to excessive heat, with room temperatures documented between 81.3°F and 84.3°F. Multiple residents complained of being excessively hot and uncomfortable for several days, with some describing difficulty sleeping and feeling as if they were overheating. Resident Council meeting minutes over several months also documented ongoing concerns about temperature regulation, indicating that the issue was persistent and not adequately addressed by facility leadership. Temperature monitoring logs provided by the facility only included common areas and did not document temperatures in individual resident rooms. The logs showed that temperatures were only checked twice a month, rather than more frequently, and did not reflect the elevated temperatures experienced by residents. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm or distress, yet there was no evidence that the facility consistently monitored or responded to unsafe room temperatures until after the deficiency was identified by surveyors.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Took temperatures throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Provided facility-wide staff abuse/neglect education, verified through staff interview and record review of post-test results.
- Ensured no staff will be permitted to work until they are reeducated on Abuse and Neglect policies.
- Education included a written competency test to include who and when to notify when a resident room is at or above 81 degrees.
- Education included information on where the cool zones are located, and that failure to report is considered neglect.
Failure to Maintain Safe Room Temperatures During Air Conditioning Outages
Penalty
Summary
The facility failed to maintain a safe and comfortable air temperature range for residents when the central air conditioning units in multiple halls broke down. Specifically, the central air conditioning unit for the 500 hall failed on 4/28/25, and although window air conditioning units were installed in residents' rooms, the facility did not monitor the room temperatures to ensure they remained within a safe and comfortable range. Subsequently, on 5/19/25, the central air conditioning unit for the 400 hall also broke, and the facility did not implement immediate or appropriate actions to maintain safe temperatures in residents' rooms and common areas. On 5/20/25, temperatures in various resident rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended range and creating a likelihood of serious harm or death from prolonged heat exposure. Temperature monitoring logs from January through May 2025 showed that temperatures were only documented twice a month in common areas and hallways, not in individual resident rooms. The logs indicated temperature ranges up to 80°F, but did not capture the elevated temperatures that occurred in resident rooms during the air conditioning failures. Resident interviews revealed ongoing discomfort due to excessive heat, with multiple residents reporting difficulty sleeping, sweating, and feeling unwell over several days. Resident Council minutes from January through April 2025 documented repeated concerns about temperature regulation, with residents consistently reporting that temperatures were either too hot or too cold and that the issue was not being resolved. Staff interviews confirmed that the facility attempted to repair the air conditioning units and installed window units as a temporary measure, but did not implement a comprehensive safety plan or monitor room temperatures until after the elevated temperatures were identified by surveyors. The DON acknowledged that interventions to address the heat were not implemented until 5/20/25 at 3:30 p.m., after the high temperatures had already been present. The failure to monitor and control room temperatures, despite ongoing resident complaints and known equipment failures, resulted in the determination of Immediate Jeopardy due to the risk of heat-related complications for residents.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Maintenance staff were educated on maintaining the facility temperatures between 71 degrees and 81 degrees.
- Air conditioners will be maintained in working condition.
- If an air conditioner unit fails, maintenance staff along with administration will activate the emergency plan to maintain facility temperatures between 71 and 81 degrees.
- Clinical staff education on abuse/neglect related to assessment and care of residents when the temperatures are above 81 degrees, verified by posttest results and interview.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement adequate supervision and processes on the secured dementia unit to prevent multiple avoidable incidents of resident-to-resident physical altercations among cognitively impaired residents with aggressive behaviors. Over a period of several weeks, numerous residents with severe to moderate cognitive impairment and behavioral disturbances were involved in repeated physical altercations, including hitting, scratching, and grabbing, resulting in injuries such as skin tears, scratches, and emotional distress. These incidents occurred in various locations within the secured unit, including hallways, resident rooms, the dining room, and the activity room, often without staff present to intervene or prevent escalation. Care plans for residents with known aggressive behaviors and wandering tendencies were found to be insufficiently individualized and did not consistently include interventions to ensure adequate supervision or to protect other residents from harm. In several cases, residents with a history of aggression or wandering were not monitored closely enough, leading to altercations when they entered other residents' rooms or were in close proximity to others. Documentation revealed that staff were sometimes unaware of residents' whereabouts or did not witness the altercations, and in some cases, staff only became aware of incidents after hearing raised voices or residents calling for help. Behavioral monitoring and documentation of target behaviors for psychotropic medication use were also lacking or incomplete. The facility's failure to provide necessary structures and supervision resulted in physical injuries to several residents and created a likelihood of serious harm to others. The pattern of incidents demonstrated a lack of effective oversight and intervention for residents at high risk for aggressive behaviors, despite their known diagnoses of dementia, mood disorders, and behavioral disturbances. The deficiency was determined to be at the Immediate Jeopardy level due to the ongoing risk and actual harm experienced by residents on the secured dementia unit.
Removal Plan
- Educate the Administrator and Director of Nursing on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Educate staff on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Give specific examples of behavioral patterns that potentially lead to resident-to-resident altercations such as wandering patterns and behaviors, proximity of residents, verbal queues, and physical queues.
- Initiate enhanced monitoring and oversight by facility leadership over the secured unit to monitor patient care areas and resident rooms for resident behaviors that could lead to resident-to-resident altercations.
- Ensure that enhanced oversight of the secured unit is in place.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect residents' right to be free from abuse by not having effective processes in place to supervise cognitively impaired residents with known aggressive behaviors. Multiple incidents occurred in which residents with histories of aggression, wandering, or agitation were not adequately supervised, resulting in avoidable resident-to-resident altercations. These altercations led to physical injuries, including scratches and skin tears, among several residents. Specific events included residents hitting, scratching, or otherwise physically assaulting each other in various locations such as hallways, activity rooms, and dining areas. In several instances, residents with dementia or behavioral disturbances wandered unsupervised into other residents' rooms, leading to confrontations and injuries. Staff were observed not supervising residents at critical times, and altercations occurred without immediate staff intervention. The facility's monitoring program, which involved staff rounding every 15 minutes, was not sufficient to prevent these incidents. The facility's own records and staff interviews confirmed that incidents of resident-to-resident aggression continued to occur despite the implementation of monitoring programs. The Director of Nursing acknowledged the high frequency of such altercations, and the Administrator verified multiple incidents of physical abuse between residents. The lack of adequate supervision and ineffective monitoring processes directly resulted in physical harm to several residents and led to a determination of Immediate Jeopardy.
Removal Plan
- The Risk Consultant educated the Administrator and Director of Nursing on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse.
- Administrator educated staff on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor. 147 out of 147 staff members were educated.
- Administrator educated staff on abuse, neglect, and exploitation as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse. 147 out of 147 staff members were trained.
- A Quality Assurance and Assessment meeting was held. Psychiatric services attended with the facility interdisciplinary team and reviewed high risk residents with behaviors. Medications and care planned interventions for behaviors were reviewed.
- Psychiatric service visits were increased for high-risk residents.
- Facility leadership along with the interdisciplinary team planned for enhanced oversight of the secured unit to monitor hallways and common areas for negative behaviors that could lead to a resident-to-resident altercation. Enhanced oversight was initiated.
- Two staff were assigned per shift to conduct enhanced oversight.
- The Administrator or designee is responsible for ensuring that enhanced oversight of the secured unit is in place.
- A qualified activity staff member was assigned to activities in the secured unit.
- A Quality Assurance meeting was conducted to review the effectiveness of the implemented interventions.
Failure to Follow Physician Orders and QAPI Process in Hypoglycemia Event
Penalty
Summary
The facility failed to utilize its Quality Assessment and Performance Improvement (QAPI) process to investigate, identify, and implement an effective performance improvement plan regarding the management of a resident's change in condition and adherence to physician orders. Specifically, a resident with Type 2 Diabetes Mellitus and a history of blood sugar monitoring experienced multiple episodes of hypoglycemia. On one occasion, an LPN administered glucose gel without a physician's order and did not notify the provider when the resident's blood sugar was 72. Subsequently, the resident became less responsive, and further blood sugar checks revealed dangerously low values. Despite a physician's order to administer Glucagon intramuscularly and send the resident to the emergency room if there was no positive response, the facility staff did not follow these instructions. When the resident's blood sugar dropped below 60 for a second time and the resident was unresponsive, the provider was not notified, Glucagon was not administered as ordered, and the resident was not sent to the emergency room. The resident's condition continued to deteriorate, with a blood sugar value of 32, and only then was emergency medical services contacted. The resident was transported to a hospital and did not survive. Interviews and record reviews revealed that the facility's QAPI process did not identify this event as a reportable incident or an area in need of improvement. The DON and nurse managers reviewed the case but failed to recognize deficiencies in care, documentation, and adherence to professional standards. The facility's policies and procedures for change in condition, physician notification, and following physician orders were not implemented, leading to a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON when hypoglycemic interventions initiated.
- VPCS reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions and 5 elements of QAPI, root cause analysis, QAPI at a glance, and QAPI self-assessment tool.
- The Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and hour report review during clinical standup and stand down meeting, and maintaining QA/PI process.
- An Ad Hoc QAPI meeting was convened to review the components of ongoing PIP and review the findings of F867 QAPI/QAA.
Failure to Follow Hypoglycemia Protocol and Physician Orders Results in Immediate Jeopardy
Penalty
Summary
A facility failed to provide treatment and care according to professional standards of practice for a resident experiencing a change in condition related to hypoglycemia. The resident, who had a history of Type 2 Diabetes Mellitus and was under orders for regular blood glucose monitoring, experienced a series of low blood sugar readings. At one point, an LPN administered glucose gel without a physician's order and did not notify the provider of the resident's low blood sugar value. Subsequent blood sugar checks revealed further declines, and the resident became less responsive. Despite a physician's order to administer Glucagon intramuscularly if blood sugar dropped below 60 and to send the resident to the emergency room if there was no positive response, the facility did not follow these orders. When the resident's blood sugar dropped to 50 and then to 32, Glucagon was not administered as directed, the provider was not notified, and the resident was not sent to the emergency room as required. Documentation of blood sugar checks and interventions was incomplete, and the facility's policies for change in condition and physician notification were not followed. The resident was eventually transported to the hospital by emergency medical services but did not survive. Interviews with staff and review of records confirmed that physician orders were not followed, documentation was lacking, and professional standards for the management of hypoglycemia were not met. The failure to implement appropriate interventions and notify the physician placed all residents at risk and resulted in a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated.
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