Health inspection·September 17, 2021

Magnolia Rehabilitation and Nursing Center "A" Citation Title 22, Division 5, Chapter 3, Article 3, Section 72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from the health professional involved in the care of the patient. Initial assessment shall commence within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Code of Federal Regulation (CFR): § 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 facility failed to ensure the licensed nursing staff promptly responded, assessed and provided immediate care to Patient A when it was reported Patient A was unresponsive. This inaction resulted in a three hour and 45 minute delay in care and treatment to Patient A. The facility also failed to obtain a physician's order for blood sugar monitoring for Patient A who had a diagnosis of DM II (diabetes mellitus type 2 - disease affecting blood sugar levels) while receiving routine oral hypoglycemic medication (medication to lower blood sugar). These failures resulted in Patient A's blood sugar not being managed and resulted in Patient A to experience an altered level of consciousness and hypoglycemia. Additionally, the facility delayed in providing necessary care and notifying Patient A's physician of a change in condition resulting in Patient A being transferred to the acute hospital for medical treatment due to hypoglycemia (low blood sugar). On August 26, 2020, at 9:55 a.m., an unannounced visit to the facility was conducted to investigate a facility reported incident involving Patient A. On August 26, 2020, at 10:13 a.m., the Assistant Administrator (AA) was interviewed. The AA stated Patient A was no longer in the facility. Patient A was a 73 year old male admitted to the facility on July 27, 2020, with diagnoses including diabetes mellitus (a disease affecting blood sugar levels), and hypertension (high blood pressure). Review of Patient A's facility record found the patient was sent to the acute hospital via emergency ambulance on August 2, 2020. The "ADMISSION ORDERS," dated July 27, 2020, indicated, "Glipizide (medication to lower blood sugar) 10 mg (milligram) tab (tablet) po (by mouth) BID (twice a day) for DM (Diabetes Mellitus)..." The physician's "History and Physical," dated August 1, 2020, indicated, "...TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATION...Monitor glucose (blood sugar) bid (twice a day) and PRN (as needed)..." The "PATIENT CARE PLAN: DIABETES MELLITUS," dated July 27, 2020, indicated, "...Monitor BS (blood sugar) per MD (medical doctor) order." Patient A's physician orders and the MAR (Medication Administration Record) for the months of July 2020 and August 2020 were reviewed. There was no documentation that blood sugar monitoring was ordered or conducted for Patient A for the months of July 2020 and August 2020. On August 26, 2020, at 11:55 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated blood sugar monitoring should have been ordered for Patient A upon admission. The DON stated the facility failed to monitor Patient A's blood sugar level. A review of the "NURSING CARE NOTES," dated August 2, 2020, at 10:45 a.m., indicated, "...Noted resident to be unresponsive, cold, clammy. Performed sternal (area on mid chest) rub did not have any reaction from resident...BGL (blood glucose level) reading of 27 (normal range 70 -100)...call 911 to send to ED (Emergency Department)..." On September 15, 2020, at 11:50 a.m., a telephone interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 confirmed Patient A was assigned to her on August 2, 2020. CNA 1 stated at 7 a.m., she tried to wake up Patient A by calling (Patient A's name) and shaking the patient. CNA 1 stated, "He wouldn't wake up." CNA 1 stated another CNA came and tried to wake up Patient A but Patient A would not wake up. CNA 1 stated she reported to Licensed Vocational Nurse (LVN) 1 that Patient A would not wake up. CNA 1 stated at 9 a.m., on August 2, 2020, she went back to Patient A and tried to wake him up. CNA 1 stated Patient A still would not wake up. CNA 1 stated she reported to LVN 1 that Patient A still would not wake up. CNA 1 stated the third time (no time stated), she asked LVN 1 if she had been in to see Patient A because he was still sleeping. CNA 1 stated a little while later she saw Patient A being sent out to the hospital. On September 17, 2020, at 1:42 p.m., a telephone interview was conducted with LVN 1. LVN 1 stated at 7 a.m., on August 2, 2020, she made her rounds and found Patient A sleeping and snoring a lot. LVN 1 stated CNA 1 reported to her that she tried to serve Patient A breakfast but Resident 1 would not wake up. LVN 1 stated she told CNA 1 to let Patient A rest because she assumed he got to sleep late. LVN 1 stated she did not go check or assess Patient A at that time. LVN 1 stated she went into Patient A's room again at 9 a.m., on August 2, 2020, to give Patient A his routine medication. LVN 1 stated she tried to wake Patient A by calling his name and shaking Patient A but he did not wake up. LVN 1 stated she continued to give medications to other residents. LVN 1 stated she did not go back to Patient A's room until 10:45 a.m. LVN 1 stated at 10:45 a.m., she went back to Patient A to give him his routine medication. LVN 1 stated Patient A was still very sleepy and would not wake up. LVN 1 stated she checked the MAR (Medication Administration Record) and noticed Patient A was on glipizide (medication to lower blood sugar). LVN 1 stated she realized it might be a blood sugar problem and noticed there was no order for Patient A to have his blood sugar monitored. LVN 1 stated she reported Patient A's condition to the Registered Nurse Supervisor (RN 1) at 10:45 a.m., on August 2, 2020, (three hours and 45 minutes after it was first reported to LVN 1 that Patient A would not wake up). LVN 1 stated when RN 1 checked Patient A's blood sugar it was 21 (70-100 is the normal range level). LVN 1 stated she should have notified RN 1 when she could not wake Patient A at 9 a.m., so RN 1 could have checked Patient A's blood sugar sooner. On September 17, 2020, at 2:25 p.m., a telephone interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the LVNs were expected notify the RN Supervisor immediately for any change in a resident's condition. On September 22, 2020, at 12:10 p.m., a telephone interview was conducted with RN 1. RN 1 stated on August 2, 2020, at 10:45 a.m., CNA 1 came to her and reported that Patient A was not waking up and did not eat breakfast. RN 1 stated CNA 1 told her she felt something was wrong. RN 1 stated she immediately went to assess Patient A. RN 1 stated Patient A's blood sugar was "super low." RN 1 stated she called Patient A's physician and Patient A was sent out to the hospital via emergency ambulance. A review of the acute hospital record dated August 2, 2020, indicated Patient A was admitted to the DOU (Direct Observation Unit - a unit that provides a second highest level of care) with a diagnosis of hypoglycemia and sulfonylureas overdose (overdose from blood sugar medication). The facility's policy and procedure titled, "Change in a Resident's Condition or Status," dated February 2014, was reviewed. The policy indicated: "...Our facility shall promptly notify the...Attending Physician...of changes in the resident's medical/mental condition and or status...The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician...when there has been...A significant change in the resident's physical/emotional/mental condition..." The facility's policy and procedure titled, "Diabetes - Clinical Protocol," dated October 2010, was reviewed. The policy indicated "...For the resident on oral (by mouth) medication(s) who is well controlled: monitor blood glucose levels at least twice weekly (or more frequently if there is a change in drugs or drug dosages)...For the resident receiving oral medication(s) who is poorly controlled: monitor blood glucose levels twice to four times daily as needed...The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management...The staff will incorporate such parameters into the Medication Administration Record..." Therefore it was determined that the facility failed to respond and provide immediate care to Patient A when it was reported that the patient was unresponsive. This failure resulted in the delay of Patient A's physician being notified of the significant change in condition for approximately three hours and 45 minutes, at which time the patient experienced an altered level of consciousness due to a blood sugar level of 27 mg/dl which required emergency treatment at the acute hospital. The facility also failed to obtain a physician order to monitor Patient A's blood sugar when that facility was aware upon admission that the patient had a diagnosis of diabetes mellitus and was receiving an oral hypoglycemic agent twice a day. The above violations presented either and imminent danger that death or serious harm would result or a substantial probability of death or serious harm to the patient.