§ 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.
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Observations:
Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings as per order for one out of three residents (Resident R1).
Findings include:
Review of the facility policy "Diabetes - Clinical Protocol" dated 1/2/25, indicated the physician will order desired parameters for monitoring and reporting information related to blood sugar management. The staff will incorporate such parameters into the Medication Administration Record (MAR).
Review of the admission record indicated Resident R1 was admitted on 8/6/24.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/27/25, indicated the diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), anemia (the blood doesnt have enough healthy red blood cells), and high blood pressure.
Review of Resident R1's physician orders dated 5/25/25, indicated Insulin Lispro (a short acting, manmade version of human insulin) inject subcutaneously as per sliding scale:
If 50 - 199 =1 unit (less than 80 call MD)
200 - 249 = 2units;
250 - 299 = 3units;
300 - 349 = 4 units;
350 - 399 = 5 units;
400 - 449 = 6 units
greater than 400 call MD or CRNP, with meals for diabetes, hold if resident does not eat.
Review of Resident R1's care plan dated 3/12/25, indicated the resident's blood glucose level will be within desired range.
Review of Resident R1's glucose log indicated the following:
6/7/25, at 8:00 a.m. glucose was 404.
6/9/25, at 8:00 a.m. glucose was 407.
6/21/25, at 8:00 a.m. glucose was 431.
6/21/25, at 9:00 p.m. glucose was 442
6/22/25, at 9:00 p.m. glucose was 440.
6/26/25, at 8:00 a.m. glucose was 432.
7/6/25, at 8:00 a.m. glucose was 429.
7/7/25, at 8:00 a.m. glucose was 448.
7/14/25, at 8:00 a.m. glucose was 449.
7/21/25, at 9:00 p.m. glucose was 439.
Review of Resident R1's progress notes did not include notification to the physician for the glucose levels above 400 as per physician's order.
Interview on 7/22/25, at 1:30 p.m. the Director of Nursing confirmed that the facility failed to notify a physician of abnormal glucose readings as per order for Resident R1 as required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services
| | Plan of Correction - To be completed: 08/26/2025
The physician of resident R-1 was notified of the abnormal blood sugar levels. No untoward effect was noted.
Nursing staff (RN and LPN) will be in-serviced on the importance of promptly notifying providers of abnormal blood sugar levels per the provider's order.
Residents receiving blood glucose monitoring will be checked daily for their blood glucose levels for five days a week for two weeks. This includes notifying the provider, if needed, according to their ordered parameters. Then, the facility will check all residents receiving blood sugar monitoring three times per week for two weeks and then once weekly for two weeks.
Any deficient practice will be immediately corrected. All data will be forwarded to the Quality Assurance Performance Improvement committee for review to determine the need for additional monitoring and/or education.
thank you
a review of prior blood sugar levels and provider notification was undertaken, and no additional errors were noted.
The Director of Nursing or designee will be conducting the in-service training
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