| 78 |
THE PILLARS OF BILOXI |
255093 |
2279 ATKINSON ROAD |
BILOXI |
MS |
39531 |
2017-03-10 |
309 |
D |
0 |
1 |
U1S311 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to monitor, and notify Resident #10's physician of low blood glucose levels to ensure appropriate treatment and management, for one of eight (1 of 8) insulin dependent Diabetic residents reviewed. Findings include: A review of the facility's policy titled, Diabetic Therapeutic Protocol, dated 06/01/2000, revealed the physician must approve the use of the Diabetic Therapeutic Protocol for each of his/her resident's use and write a corresponding order in the medical record. Nurses will be informed of this practice upon hire and regularly thereafter. [DIAGNOSES REDACTED] Protocol: If the resident is asymptomatic, alert, and the finger stick blood glucose is less than 50 (or as indicated by the physician): 1. Give a form of carbohydrate that contains glucose. Orange juice with 2 (two) teaspoons of sugar is acceptable. If the resident is unable to swallow due to other medical conditions, give [MEDICATION NAME] one milligram intramuscular ( 1 mg. IM) now. 2. Recheck the finger stick blood glucose in 15 minutes. 3. If the finger stick blood glucose remains less than 50, and the resident remains asymptomatic, repeat the treatment. 4. Notify the physician. The physician is notified even if the resident improves. 5. If the finger stick blood glucose returns to normal, have the resident eat a meal or snack containing a form of protein, (i.e. peanut butter or cheese sandwich, milk, cheese and crackers). An observation and interview on 03/07/17 at 4:20 PM, revealed when the State Agency (SA) surveyor entered Resident #10's room, Resident #10 was lying in the bed, and observed to be sweating profusely. Resident #10's eyes were casted to the left, she was not responsive when spoken to, her skin felt cool and clammy, and she was taking shallow, quick breaths. Certified Nursing Assistant (CNA #4) was in the room with the resident at this time. CNA #4 stated when she entered the room, she found Resident #10 sweating profusely, the bed soaked with sweat and possibly urine. There were clear plastic bags containing linen, sheets and bedspreads on the floor next to the bed. CNA #4 said she had informed Licensed Practical Nurse (LPN #5) about Resident #10's profuse sweating, and had requested LPN #5 to turn the air conditioning down in the room because the resident was sweating so much. CNA #4 stated LPN #5 came into the room about five (5) minutes later, and turned the air conditioning down. CNA #4 stated she did not think LPN #5 assessed the resident when he came in the room at that time. CNA #4 did report Resident #10 was talking to her earlier when LPN #5 was in the room. The SA surveyor stepped out of the room and saw LPN #5 at the med cart in the hallway. The SA surveyor asked LPN #5 to check on Resident #10. LPN #5 entered room, and Resident #10 responded to him when he assessed her. LPN #5 stated the resident looked, and responded as she normally does, but the sweating was unusual. LPN #5 stated Resident #10 had recently returned from a hospitalization for a hypoglycemic episode, and he would check her blood sugar level. An interview with CNA #4 on 03/07/17 at 5:25 PM, for clarity regarding the time, and what she reported to LPN #5 revealed she told him at around 4:00 PM the resident was sweating, and asked if he could turn on the air conditioning. CNA #4 stated LPN #5 entered the room about five minutes later, and turned down the air conditioner. CNA #4 stated the resident was responsive at that time, and LPN #5 was coming down the hallway, and was about to get to the room. An observation of Resident #10 at 5:28 PM on 03/07/17, revealed the resident was responsive, but her responses to questions were incoherent. The resident was unable to state her name. An interview with LPN #5 on 03/07/17 at 5:30 PM, revealed LPN #5 had taken the Resident #10's blood glucose level, and it was 43 mg/dl (milligrams/deciliter). LPN #5 stated he gave her two (2) cups of Koolaid, and Med Pass, and called the attending physician (Medical Director). He stated the physician told him to check the glucose level again in about 15 minutes, and if it was still below 60 he was to administer [MEDICATION NAME] one milligram intramuscular (1mg IM). LPN #5 was observed taking the glucose level at this time. The glucose level was still 43, and LPN #5 administered the [MEDICATION NAME] IM. LPN #5 stated Resident #10 is always confused due to dementia, cannot state her name, and mostly says yes to questions. An interview with LPN #5 on 03/08/17 at 2:50 PM, regarding the hypoglycemic episode, and monitoring Resident #10's blood sugar, revealed LPN #5 stated he should have checked Resident #10's blood sugar due to the profuse sweating when CNA #4 initially reported it to him. LPN #5 stated it was hot in the room when he was called in by the CNA, and he thought the resident was sweating from the heat. An interview on 03/07/17 at 5:35 PM, with the Attending Physician confirmed he had been notified of Resident #10's hypoglycemic episode on 03/07/17 at 4:25 PM, by LPN #5. He stated he was told the resident was sweating and clammy, didn't look well, had a glucose level of 43, and the nurse had given her two cups of koolaid and med pass. The physician stated he was told the resident was responsive. He stated he instructed the nurse to check the insulin level again in 15-20 minutes, and if it was still below 60, to administer 1mg [MEDICATION NAME] IM. The physician could not recall if the resident had frequent episodes of [DIAGNOSES REDACTED], he had not been informed of any episodes since her return from the hospital, but his assistant (the Nurse Practitioner) may have information that he did not. He stated he had a lot of residents, and it was difficult to remember details. When asked if a resident with diabetes was sweating profusely would he expect the nurse to take the blood sugar level, and he said yes, sweating is a symptom of [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. IM on 3/7/17 at 5:30 PM. Further review of the MAR indicated [REDACTED]. An interview on 03/08/17 at 2:30 PM, with Registered Nurse (RN) #5 revealed she held the prescribed dose of insulin for Resident #10 on 03/07/17. She stated she had not obtained a physician's orders [REDACTED]. RN #5 stated there were no documented parameters for holding insulin for Resident #10, but she held it based on the resident's history, and nursing judgment. RN #5 stated she left early on 03/07/17, and did not report to the nurse (RN #6) relieving her that she had withheld insulin that day. A review of the physician's orders [REDACTED]. Review of Resident #10's Nurse's Notes revealed no documentation regarding the Detemir insulin was held on 3/7/17, or the resident's Physician was notified the insulin was held. A review of the facility's Weights and Vitals sheet for Blood Sugars revealed the following blood sugars documented for 3/7/17: 84mg/dl at 5:08 AM, 112mg/dl at 11:16 AM, and 43mg/dl at 5:05 PM. A review of Resident #10's Care Plan revealed Resident #10 had a Care Plan to address Diabetes originated on 09/15/16, with a revision date of 12/05/2016. There was no revision of the care plan when the resident returned from the hospital on [DATE]. The care plan had an intervention to, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased Heart Rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, Slurred speech, Lack of Coordination, staggering Gait initiated on 09/15/2015. A review of Resident #10's (MONTH) (YEAR) physician's orders [REDACTED]. A review of the Nurse's Notes for the month of (MONTH) (YEAR), revealed Resident #10 had an accu-check that read a blood glucose level of 41mg/dl 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 mg/dl. 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 the physician was notified at that time. Further review of the Nurse's Notes revealed Resident #10 was readmitted by the facility on 03/03/17, post hospitalization . A review of the facility's Weights and Vitals sheet for Blood Sugars revealed the following blood sugars documented on 3/6/17: 41mg/dl at 5:35 AM, 238 mg/dl at 11:29 AM, 155 mg/dl at 5:01 PM, and 148 at 8:53 PM. An interview on 03/08/17 at 8:30 AM, with the Attending Physician revealed he had not been notified of Resident #10 having a hypoglycemic episode on 03/06/17. The Attending Physician stated 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 of hypoglycemic episodes, or if insulin was held. The Attending Physician stated he was not notified Resident #10's insulin was held on 03/07/17, but agreed it should be with a blood glucose level of 112. He stated he would expect a nurse to take the glucose level on a resident with diabetes if the resident exhibited profuse sweating. An interview on 03/09/17 at 10:20 AM, with the Director of Nursing (DON) revealed it was expected hypoglycemic episodes, and holding insulin should be reported to the physician or physician's assistant. The DON stated the nursing staff should have been more diligent in reporting given the resident's recent hospitalization for [DIAGNOSES REDACTED], and the nursing staff had not done as good a job as they should. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) and Certified Family Nurse Practitioner (CFNP) revealed that he is the Physician's Assistant for the Attending Physician. The CFNP stated on 3/7/17, during the morning shift, he came to the facility to perform daily rounds, and follow up with the Resident #10 since her recent release back to the facility from the hospital. He stated he requested to see Resident #10's vital signs, and identified on the MAR indicated [REDACTED]. The CFNP stated he was not notified prior to inquiring about the hypoglycemic episode. The CFNP stated he also reviewed meal intakes, and decreased the resident's insulin dosage based on the information gathered. 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 that he had not been notified of the nurse holding 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 |