Other·October 18, 2022

F684 Quality of Care 483.25 Section 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The following citation was written as a result of an unannounced visit to the facility on 11/09/21 to investigate Complaint #CA00758897. As a result of the investigation, the Department determined the facility failed to ensure one of three sampled residents (Resident 1) was assessed for a change of condition and monitored for elevated blood glucose (BG) in accordance with professional standards of practice and the facility policy and procedures when: 1. There was no documented evidence that Resident 1 was assessed and monitored when she had changes in conditions with dangerously elevated BG levels; 2. The physician (Medical Doctor, MD) and Resident Representative (RR) were not notified of Resident 1's change of condition timely; and, 3. There was no documented evidence the physician order for Humalog insulin (a fast-acting medication to help control the amount of sugar in the blood) to be administered for high BG was administered as ordered on 8/14/20 for Resident 1 in the MAR (Medication Administration Record) or in the E-kit log (Emergency medication kit). These failures resulted in: 1. Resident 1 having BG at a level that was too high to measure using a glucometer (a BG measuring device) 2 a. A missed opportunity to receive timely physician orders that could have prevented further BG elevation and deterioration of Resident 1's condition, 2 b. RR being deprived of seeking alternative medical interventions, and 3. Uncertainty that Resident 1 received the Humalog insulin at the time of crisis. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result and were substantial factors in the death of Resident 1. Review of Resident 1's clinical record, Resident 1 was a long-term resident in the facility with the primary diagnosis of insulin dependent type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar [glucose]) with unspecified complications. Resident 1 was medically fragile due to her advanced age, she received nutrition and hydration through a tube in her stomach, and she had high blood pressure, high cholesterol, and unspecified dementia (loss of cognitive [mental/reasoning] function). Review of Resident 1's clinical record, MDS (Minimum Data Set, an assessment tool), dated 7/11/20, indicated Resident 1's cognitive function was severely impaired in the Brief Interview for Mental Status evaluation. Review of the care plan for communication, revised 5/7/19, indicated staff were to anticipate Resident 1's needs due to her communication deficit, "staff to anticipate needs prn [as needed]" due to, "...she [Resident 1] is sometimes understood and sometimes understands." Review of Resident 1's clinical records, "Progress Notes", dated 8/14/20 at 9:01 a.m., written by Licensed Nurse (LN) 1 indicated, "...blood sugar level reading 'HI', [MD Name] notified." LN 1 entered another progress note on 8/14/20 at 1:54 p.m. regarding the insulin order and the resident's death, "...upon blood sugar check, BG readings say 'HI' and [MD Name] notified and order received for Humalog, sliding scale [the dose of insulin based on blood glucose level]; given 7 units. morning meds [medications] given, at 09:59 AM resident was unresponsive to verbal command, unresponsive to touch, no chest movement, no BP [blood pressure], pulse and O2 saturation [the amount of oxygen traveling through the body in red blood cells]...pronounced resident expired at 10:05 AM..." Review of the manufacturer's user instruction manual for the glucometer stipulated, "If your blood glucose is above 600 mg/dL, you will receive a "Hi." Repeat the test with a new test strip. If this message shows again, contact your healthcare professional immediately!. Contact your physician for advice if...you have symptoms of high blood glucose. These symptoms include dry mouth, thirst, frequent urination, nausea, vomiting, blurred vision, sleepiness, or abdominal pain." Review of Resident 1's clinical records, "Death Certificate Information Request", dated 8/19/20, indicated the resident expired on 8/14/2020 at 10:05 a.m. and the cause of her death was, "IMMEDIATE CAUSE: (A) Cardiac arrest [the heart stop beating suddenly] DUE TO: (B) Diabetes type 2", issued by the facility MD office. Review of the clinical records, "Order Summary Report", for August 2020, indicated Resident 1 physician orders for diabetes which included BG monitoring twice a day, a long-acting insulin administration at bedtime, administration as follows: a. Order date: 5/6/2019 for glucose monitoring twice daily, "FSBS [Finger Stick Blood Sugar, one method of blood glucose check by pricking fingertips and using a glucometer to measure the blood glucose level at that moment] Q [every] Morning & HS [and at bedtime]. Call MD if BG<60 [less than 60] or >400 [greater than 400] two times a day". b. Order date: 7/10/2020 for a long-acting insulin "Lantus Solution 100 units/ml (Insulin Glargine) Inject 7 units subcutaneously [the tissue layer between the skin and the muscle] at bedtime related to Type 2 diabetes mellitus with unspecified complications". 1. Review of Resident 1's clinical record, Weights and Vitals Summary, for Blood Sugar (Glucose) for August 2020, indicated Resident 1's baseline BG readings ranged from 92 mg/dL to 157 mg/dL. The Blood Sugar log indicated Resident 1 had a change of condition exhibiting abnormal BG readings over 200's mg/dL starting 8/10/20 four days prior to her death as follows: 8/13/20 at 9:13 p.m.: 456 mg/dL 8/13/20 at 7:05 a.m.: 293 mg/dL 8/12/20 at 9:02 p.m.: 149 mg/dL 8/12/20 at 7 a.m.: 230 mg/dL 8/11/20 at 8:15 p.m.: 220 mg/dL 8/11/20 at 8:50 a.m.: 177 mg/dL 8/10/20 at 8:32 p.m.: 212 mg/dL 8/10/20 at 7:28 a.m.: 216 mg/dL Review of the clinical records, Weights and Vitals, Pulse Summary for August 2020 indicated Resident 1's baseline pulse readings ranged from 53 bpm (beats per minute) to 86 bpm (A normal resting heart rate for adults ranges from 60 to 100 beats per minute). The Pulse Summary indicated Resident 1 had change of condition exhibiting out of her baseline pulse rates over 90 starting 8/9/21, five days prior to her death as follows: 8/14/20 at 9:43 a.m.: 110 bpm 8/13/20 at 10:04 a.m.: 100 bpm 8/12/20 at 10 a.m.: 96 bpm 8/10/20 at 3:12 a.m.: 90 bpm 8/9/20: at 10:16 a.m.: 97 bpm Review of the facility's 11/2017 policies and procedures, "CHANGE OF CONDITION, RESIDENT," indicated, "It is the policy of this facility to identify...and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner...Document assessments and interventions on the clinical record...Continue to monitor and document resident's condition at a minimum of every shift for 72 hours and as needed..." Review of the care plan for DM, dated 5/6/19, indicated the care plan goals were for Resident 1 not to have complications related to diabetes with interventions to, "Treat promptly as ordered by doctor...Monitor/document/report to MD PRN [as needed] s/sx [signs and symptoms of hyperglycemia: increased thirst...Kussmaul breathing [deep, rapid, and labored breathing], acetone breath (fruity smelling breath), stupor, coma." Review of the clinical record, "Progress Notes" from 8/10/20 through 8/14/20, indicated there was no documented evidence Resident 1 was assessed for change of condition with elevated BG or monitored her abnormal BG readings and elevated pulse rates. There was no assessment in the clinical record whether the resident had signs and symptoms of hyperglycemia as indicated in the DM care plan or in accordance with the facility policy and procedure when the resident's BG levels reached up to 293 mg/dL and 456 mg/dL. In an interview on 11/9/21 starting at 2:36 p.m., the Former Director of Nursing (FDON) verified there was no assessment when Resident 1 had a change of condition with elevated BG levels. The FDON verified there was no documented evidence that Resident 1's abnormal BG levels and pulse rates were monitored when the numbers were out of her baseline. Review of the facility's 11/2012 policies and procedures, Blood Glucose Monitoring and Quality Control, stipulated to conduct BG tests in a safe and comfortable manner, "...within the standards of nursing practice...If the blood glucose result is abnormal or beyond the established ranges ordered by the physician:..Repeat the test if a false result may have occurred...Document blood glucose level on the clinical record." Review of Resident 1's clinical records there was no documented evidence LNs repeated the resident BG check when her BG readings was abnormally high at 293 mg/dL at 7:05 a.m., at 456 mg/dL at 9:13 p.m. on 8/13/20 or when the BG reading was registered "Hi" in the glucometer in the morning of 8/14/20 to ensure the accuracy of the readings. Review of Resident 1's clinical records, "Progress Notes", dated 8/13/20 at 10:01 p.m., LN 2 indicated, "Resident blood sugar was high 456, MD notified and ordered to increase Lantus from seven units to 10 units, only for tonight, and to monitor resident for hyperglycemia..." LN 2 entered another note on 8/14/20 at 12:02 a.m., "The oncoming nurse notified during shift report to monitor resident blood sugar for hyperglycemia." Review of the Resident 1's clinical records included no documented evidence LN 2 or the oncoming nurse monitored Resident 1's blood sugar for hyperglycemia as ordered or conducted follow up FSBS checks to ensure the Lantus 10 unit dose was effective and the resident's BG level was back to her baseline. In an interview on 12/8/21 starting at 1:40 p.m., the FDON verified there was no assessment or monitoring for Resident 1's BG in the clinical record after the Resident received Lantus 10 units. The FDON stated Lantus was a long-acting insulin so LN 2 should have checked the resident's BG levels again within an hour or at least between 1 a.m. and 2 a.m. after the administration to ensure the medication was effective according to the standards of nursing practice. The FDON acknowledged it was unknown whether the Lantus 10 units administration was effective for the resident. In an interview on 12/16/21 starting at 2:20 p.m., the Director of Nursing (DON), with the Assistant Director of Nursing (ADON) present, stated she would have raised concern when Resident 1 had changes in conditions on 8/10/20 exhibiting BG levels at 200's. The DON stated LNs should have started to assess the resident then. The DON explained the glucometer displayed "Hi" when BG reading was over 600 mg/dL which indicated Resident 1's BG was over 600 mg/dL in the morning of 8/14/20. The DON acknowledged because there was no repeated BG check between her BG reading of 456 ml/dL on 8/13/20 at 9:13 p.m. and 'Hi' the next morning, it was unknown whether the Lantus 10 units administration was effective or how high and how long the resident had elevated BG. The DON acknowledged the resident's BG could have been over 700 mg/dL, 800 mg/dL or more during the night stating, "We don't know." The DON stated Resident 1 should have been checked and rechecked every 15 minutes, 30 minutes until the resident was stable. The DON stated if the resident's BG levels were not stabilized then the resident should have been sent out to an Emergency room for further treatment. 2. Review of the facility's 11/2017 policies and procedures, "CHANGE OF CONDITION, RESIDENT," stipulated, "It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner.., and notify the resident representative of the change of condition, new physician orders, and/or the need to seek acute medical intervention." Review of the resident's clinical record, there was no documented evidence MD was notified when the resident had change of condition showing abnormal BG results on 8/10, 8/11, 8/12 and 8/13 a.m. or having elevated pulse rates until the resident's BG was at 456 mg/dl on 8/13/20 at 9:13 p.m. Review of Resident 1's clinical records indicated Resident 1's Representative (RR) had not been notified when the resident had change of condition on 8/10/20, 8/11/20, 8/12/20 and 8/13/20. Review of Resident 1's clinical records, "Progress Notes" on 8/14/20 at 1:54 p.m., by LN 1, RR was notified after the resident was expired on 8/14/21 at 1:54 p.m.,"...Dr.[Name] assessed and pronounced resident expired at 10:05 AM. RP [RR's name] notified at 10:10 AM. called [Name of Mortuary] and remains picked up at 13:15 hours [1:15 p.m.]." In an interview on 11/9/21 at 4:06 p.m., LN 1 verified he called the RR after Resident 1 was pronounced dead on 8/14/20 stating, "Son [RR] was shocked." In an interview on 12/8/21 starting at 1:40 p.m., the FDON verified the MD was not notified until the resident's BG level was at 456 mg/dL on 8/13/20 and RR was notified after the resident was expired. The FDON stated LN should have contacted the MD when the resident had a change of condition, and her BG was elevated to 293 mg/dL in the morning of 8/13/20. The FDON acknowledged that had the MD been notified then, there was an opportunity to bring the resident's BG level down and possibly prevent her BG from spiking up to 456 that evening. The FDON acknowledged the resident's family did not have the opportunity to seek alternate medical treatment options when the resident had a change in condition. In an interview on 12/16/21 starting at 2:20 p.m., the DON, with ADON present, acknowledged LNs should have notified the MD when Resident 1 had a change of condition and stated a Physician Assistant (PA) was present in the facility every day. The DON stated she was unsure why LNs did not talk to the PA about Resident 1's condition. The DON acknowledged timely MD notification was important to decide whether the resident was to be treated in the facility or to send out to an emergency room for higher level treatment. The DON stated it was the facility policy to notify the RR when the resident had a change of condition, and that Resident 1's RR was not notified but contacted on 8/14/20 after the resident had expired. 3. Review of Resident 1's clinical records, "Progress Notes", dated 8/13/20 at 10:01 p.m., LN 2 indicated, "Resident's blood sugar was high at 456, MD notified and ordered to increase Lantus from seven units to 10 units, only for tonight, and to monitor resident for hyperglycemia..." Review of Resident 1's clinical records, "Progress Notes", dated 8/14/20 at 1:54 p.m., LN 1 indicated, "...upon blood sugar check, BG readings say 'HI' and [MD Name] notified and order received for Humalog [a short acting insulin, a medication to help control the amount of sugar in the blood], sliding scale [the dose of insulin based on blood glucose level]; given 7 units. morning meds [medications] given, at 09:59 AM resident was unresponsive to verbal command, unresponsive to touch, no chest movement, no BP [blood pressure], pulse and O2 saturation [the amount of oxygen traveling through your body with your red blood cells]...pronounced resident expired at 10:05 AM..." Review of the clinical records, "Medication Administration Records" (MAR) for August 2020 indicated Resident 1 did not have Humalog Insulin sliding scale administration in her medication regimen. The August 2020 MAR did not indicate Resident 1 received the breakthrough Humalog insulin in the morning of 8/14/20 when the resident BG reading was "Hi' and unregistered on the glucometer. In an interview on 11/9/21 at 2:36 p.m., LN 1, who took care of the resident during the morning shift when the resident was expired, denied he received any