| 71 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2017-03-10 |
157 |
D |
0 |
1 |
U1S311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure the physician was notified of a resident's low blood glucose level per the facility's diabetic protocol regarding blood glucose parameters for reporting, and failed to ensure the physician was notified when routine insulin was withheld for one (1) of eight (8) insulin dependent residents reviewed. (Resident #10). Findings include: A review of the facility's policy titled, Physician Notification of Change of Condition or Status, dated (MONTH) 1, 2000, revealed it was the policy of the facility to provide a mechanism for informing the resident's physician of changes that affect the resident. The procedure included the attending physician would be notified when there was a significant change in the resident's physical, mental, or psychological status, or when there was a need to alter treatment significantly. A review of the facility's policy titled, Diabetic Therapeutic Protocol, dated 06/01/2000, revealed a [DIAGNOSES REDACTED] Protocol that if a resident was asymptomatic, alert, and the finger stick blood glucose was less than 50, staff was to give a form of carbohydrate that contained glucose, recheck the finger stick glucose in 15 minutes, and if it remained less than 50, and the resident remained asymptomatic, repeat the treatment then notify the physician. The physician was to be notified even if the resident improved. A review of Resident #10's (MONTH) (YEAR) physician's orders [REDACTED]. A review of Resident #10's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. A review of the Nurse's Notes for the month of (MONTH) (YEAR) confirmed the resident had an accucheck that read a low blood glucose level of 41 at 6:00 AM on 03/06/17. The note further indicated the resident was alert and responsive, was given a form of carbohydrate that contained glucose, and another accucheck was taken at 6:30 AM that read a blood glucose level of 48. Treatment was repeated, and the next blood glucose level was obtained at 6:50 AM, and read 82. There was no indication in the Nurse's Notes Resident #10's physician was notified at that time of the low blood glucose. Further review of the Nurse's Notes revealed no indication Resident #10's physician was notified of the insulin being held on 03/07/17. An interview on 03/08/17 at 8:20 AM, with the Resident #10's attending Physician revealed he had not been notified of Resident #10 having a hypoglycemic episode on 03/06/17. He thought that perhaps his Physician's Assistant (a Certified Family Nurse Practitioner) may have been notified. The physician stated he expected that he or his assistant would be notified. Resident #10's attending Physician stated he was not notified the insulin was held on 03/07/17. An interview on 03/08/17 at 2:30 PM, with Registered Nurse (RN) #5 revealed she had not notified Resident #10's Physician, or obtained a physician's orders [REDACTED].#10's insulin on 03/07/17. RN #5 stated she should have contacted the physician to obtain an order to hold the insulin, but failed to do so, however, she felt she made the correct decision to hold the insulin based on Resident #10's glucose level, and nursing judgment. RN #5 stated there were no documented parameters for Resident #10. RN #5 stated she left early on 03/07/17, and did not report to the nurse relieving her that she had withheld Resident #10's insulin that day. An interview on 03/09/17 at 10:20 AM, with the Director of Nursing (DON) revealed hypoglycemic episodes, and holding insulin should be reported to the physician or physician's assistant. The DON stated the nursing staff should be more diligent in reporting given the resident's recent readmission on 3/3/17, due to hospitalization for [DIAGNOSES REDACTED]. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) and the Certified Family Nurse Practitioner (CFNP) revealed the CFNP was Resident #10's attending Physician's assistant. The CFNP stated he came to the facility to perform daily rounds on 03/06/17, during the morning shift. The CFNP stated he saw Resident #10 to follow up on her return from a recent hospitalization , and requested from the nurse to see her vitals. The CFNP stated he identified on the MAR indicated [REDACTED]. The CFNP stated he had not been informed of the episode prior to his review of the MAR. The CFNP stated he would expect to be notified of hypoglycemic episodes, and was easily accessible to staff as was the attending physician. The CFNP stated he had not been notified of the nurse holding the insulin on 03/07/17. A review of Resident #10's Face Sheet revealed Resident #10 was originally admitted by the facility on 06/18/10, and had current [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/17, revealed Resident #10 was assessed by staff for cognitive skills for daily decision making, and found to be moderately impaired, indicating decisions were poor, and cues/supervision were required. |
2020-09-01 |