§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.
§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.
§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
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Observations:
Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to document notifications of medical providers of increased and decreased capillary blood glucose levels and/or failed to document recheck of out-of-range blood sugar levels for three of seven residents (R25, R25, and R72).
Findings:
Review of the facility policy, "Physician Notification" dated 1/22/26, indicated, "Upon identification of a resident who has clinical changes, change in condition, or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician as indicated." The policy further stated to document findings related to the change in condition and physician notification and response.
Review of the facility policy, "Hypoglycemia Protocol" dated 1/22/26, indicated that for hypoglycemia (low blood sugar level) or hyperglycemia (high blood sugar level) the facility staff should "Recheck the blood sugar" and "Notify the MD (doctor of medicine)."
Review of the clinical record indicated Resident R11 admitted to the facility on 10/14/19.
Review of the Minimum Data Set (MDS, periodic assessment of resident care needs dated 5/11/26, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).
Review of Resident R11's care plan initiated 10/14/19, revised on 4/30/26, for diabetes indicated to monitor for signs and symptoms of hyperglycemia and hypoglycemia and notify provider and indicated to provide insulin as ordered by the physician.
Review of a current physician order dated 1/15/25, indicated to inject Novolin insulin (an injectable medication to treat diabetes) per sliding scale, and indicated if Resident R25's blood sugar level was less than 60 (milligrams per deciliter) to call the MD (Doctor of Medicine) and document in the progress notes.
Review of Resident R11's blood sugar record revealed the following decreased blood sugar levels without documentation that the provider was notified:
5/06/26, at 7:34 a.m. - 61 mg/dL (milligrams per deciliter), no documentation of recheck.
5/15/26, at 8:18 a.m. - 57 mg/dL, no documentation of recheck
Review of the clinical record indicated Resident R25 admitted to the facility on 9/25/24.
Review of the MDS dated 3/20/26, included diagnoses of diabetes and high blood pressure.
Review of Resident R25's care plan initiated 9/24/24, revised on 3/17/26, for diabetes indicated to monitor for signs and symptoms of hyperglycemia and hypoglycemia and notify provider and indicated to administer diabetes medications as ordered.
Review of a physician order dated 9/14/25-4/21/26, indicated to inject Novolog insulin (an injectable medication to treat diabetes) per sliding scale, and indicated if Resident R25's blood sugar level was less than 60 (mg/dL) to call the MD.
Review of a physician's order dated 4/29/25, indicated to administer glucagon emergency injection kit as needed for "hypoglycemic protocol for Accu-check less than or equal to 70 (mg/dL) and resident UNRESPONSIVE or UNABLE to swallow. Administer Glucagon IM (intra-muscularly) and recheck in 15 minutes.
Review of a physician's order dated 6/20/25, indicated to administer glucose gel 40% "as needed for hypoglycemia. If unresponsive and Accu-check (blood sugar check) is less than 70 (mg/dL) administer glucose gel, contact physician, and enter PN (progress note)."
Review of Resident R25's blood sugar record, medication administration record (MAR), and progress notes for 5/20/26, revealed the following:
-7:14 a.m. - Blood sugar check 61 mg/dL, no documentation of recheck.
-11:32 a.m. - Blood sugar check 472 mg/dL.
-4:00 p.m. - MAR: Glucose gel 40% given.
-4:00 p.m. - Note: "Resident was leaning over in w/c (wheelchair), diaphoretic, warm and clammy touch, BS 29 (mg/dL) resident in and out of responsiveness, glucose gel administered as resident was able to swallow without difficulty." This progress note had no further documentation of notification to the provider.
-4:15 p.m. - Blood sugar check 46 mg/dL
-4:30 p.m. - Blood sugar check 37 mg/dL
-4:30 p.m. - Note: Glucose gel is ineffective.
-4:36 p.m. - Administration of glucagon injection.
-4:36 p.m. - Note: "Resident's BS (blood sugar) showing minimal improvement, resident remains in and out of unresponsiveness, warm, clammy, and diaphoretic, Glucagon injection administered per order." This progress note had no further documentation of notification to the provider.
-4:47 p.m. - Blood sugar check 79 mg/dL
-4:47 p.m. - Note: Glucagon injection is effective.
Review of the clinical record indicated Resident R72 admitted to the facility on 10/6/25.
Review of the MDS dated 4/14/26, included diagnoses of diabetes and osteomyelitis (inflammation of the bone or bone marrow, usually due to infection).
Review of Resident R72's care plan initiated 10/6/25, revised on 3/17/26, for diabetes indicated to monitor for signs and symptoms of hyperglycemia and hypoglycemia and notify the provider.
Review of a physician order dated 3/16/26, reordered 4/18/26 (discontinued 4/29/26), indicated to inject insulin lispro (an injectable medication to treat diabetes) per sliding scale, and indicated if Resident R72's blood sugar level was less than 60 or greater than 400 mg/dL to call the MD.
Review of a current physician order dated 4/29/26, and reordered 5/5/26, indicated to inject insulin lispro per sliding scale, and indicated if Resident R72's blood sugar level was less than 70 or greater than 450 mg/dL to call the MD.
Review of Resident R72's blood sugar record and progress notes revealed the following elevated blood sugar levels without documentation that the provider was notified or documentation of a blood sugar recheck:
4/11/26, at 7:46 p.m. - 425 mg/dL
4/24/26, at 8:54 p.m. - 406 mg/dL
4/28/26, at 8:30 p.m. - 554 mg/dL
5/28/26, at 8:01 p.m. - 476 mg/dL
6/04/26, at 8:31 p.m. - 491 mg/dL
6/06/26, at 1:10 p.m. - 466 mg/dL
During an interview on 6/18/26, at 10:24 a.m. the Director of Nursing confirmed that the clinical record failed to reveal documentation of a notification to the provider and or documentation of blood sugar rechecks completed for the above residents.
During an interview on 6/18/26, at approximately 12:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to document notifications of medical providers of increased and decreased capillary blood glucose levels and/or failed to document recheck of out-of-range blood sugar levels for three of seven residents.
28 Pa. Code 201.18 (b)(1) Management
28 Pa. Code 211.10 (c)(d) Resident care policies
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services
| | Plan of Correction - To be completed: 07/17/2026
An audit was completed to assure all orders include instructions on accu-chek parameters, which include calling MD or CRNP if blood accu-chek is out of parameters, interventions and documentation of notification to MD or CRNP per orders.
All nurses received education regarding calling MD and/or CRNP when resident's blood sugar is out of parameters, as well as required interventions and required documentation of the orders received from the MD and/or CRNP.
Director and designee added all resident's MD recommended parameter's in resident's orders, so the dashboard in Point Click Care would flag each time an accu-chek is recorded outside of MD ordered parameters. This would alert administration and/or supervisor when blood sugar is documented outside of MD ordered parameters. The Director of Nursing or designee will review the dashboard daily for any blood sugars that are recorded outside of parameters to assure that the required protocol was followed. This is an additional measure to assist in maintaining compliance.
This P.O.C will be on-going with review at monthly QAPI meetings to assure compliance is maintained.
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