§ 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.
|
Observations:
Based on a review of hospital, and clinical records, and interviews with staff, it was determined that the facility failed to properly assess, monitor, and provide treatment for a resident with known condition of diabetes resulting in the harm of hospitalization after experiencing hypoglycemia (low sugar in blood) for one of three residents reviewed (Resident CL1).
Findings include:
Review of Resident CL1's clinical record revealed Resident CL1 was admitted to the facility on September 22, 2024.
Review of Resident CL1's diagnosis list includes Diabetes Mellitus (group of metabolic disorders characterized by a high blood sugar level over a prolonged period) long-term (current use of insulin), and Chronic Kidney Disease.
Review of Resident CL1's hospital records including document labeled "Clinical Summary" created on September 22, 2024, revealed the resident was on blood sugar monitoring three times daily. The same document indicated, regarding Resident CL1's DM (Diabetes Mellitus), "with the use of insulin, the plan was to continue to monitor POTC (point-of-care test) Accuchecks (machine used to check blood glucose); Hypoglycemia and Hyperglycemia (high blood sugar) protocol in place; and encourage p.o. (by mouth) intake."
Review of Resident CL1's hospital record "Emergency Department Provider Notes" dated September 21-22, 2024, revealed the resident's POTC glucose was checked. A laboratory report dated September 21, 2024, showed a "Glucose level of 166 mg/dl (Normal range 80-130 mg/dl)."
Review of Resident CL1's physician orders dated September 22, 2024, revealed the following orders: Insulin Aspart Protamine & Aspart Suspension (Aspart 70/30- premixed insulin that starts to work within 10 to 20 minutes after injection, peaks in 2 hours, and keeps working for up to 24 hours) Inject 25 units two times daily.; Insulin Aspart Solution (fast-acting insulin) Inject 16 units one time a day (Scheduled at noon); Insta-Glucose Gel 77.4% Give one dose by mouth as needed for blood glucose less than 70, for a patient who is arousable conscious, and able to swallow if repeat blood glucose is below 70 mg/dl. Continue to hold all diabetic medications until the provider authorizes resumption; Glucagon Emergency Kit 1 mg Inject 1 mg intramuscularly as needed for blood glucose less than 70, not arousable conscious or able to swallow if repeat blood glucose is below 70 mg/dl and the patient is not arousable, conscious, or able to swallow. Continue to hold all diabetic medications until the provider authorizes resumption, and the Hypoglycemia protocol observes signs/symptoms of Hypoglycemia as needed if blood glucose is less than 70 mg/dl or ordered low parameters follow the Hypoglycemia protocol.
Review of Resident CL1's clinical record failed to reveal a blood glucose monitoring order despite the notation within hospital record of insulin administration and Hypoglycemia protocol orders.
Interview with the Director of Nursing (DON) was conducted on October 7, 2024. The DON agreed no blood glucose order was done since it was not indicated on the resident's hospital discharge summary/instructions.
Review of Resident CL1's clinical record failed to reveal facility staff clarified the admission orders to the physician, regarding how to monitor for hypoglycemia and how to implement hypoglycemia protocol without monitoring Resident CL1's blood glucose level.
Review of Resident CL1's September 2024, Medication Administration Record (MAR) revealed the resident was administered Insulin Aspart 70/30, 20 units on September 23, 2024, at 8:00 a.m., and Insulin Aspart 16 units at noon.
Review of Resident CL1's vitals revealed Resident CL1's blood glucose was checked on September 23, 2024, at 7:30 a.m., with a result of 187 mg/dl, and September 23, 2024, at 11:30 a.m., with a result of 100 mg/dl.
Interview with the Director of Nursing on September 23, 2024, revealed the nurse checked Resident CL1's blood glucose before the above insulin administration as a "nursing judgment."
Review of Resident CL1's physician's progress notes dated September 23, 2024, at 1:11 p.m., revealed under assessment a Plan for DM, "continue insulin, and monitor blood sugar."
Review of Resident CL1's clinical record failed to reveal an order for blood sugar monitoring.
Review of Resident CL1's nursing progress notes dated September 23, 2024, at 10:46 p.m., revealed around 4:00 p.m., the resident complained of a headache, the charge nurse assessed the resident and was administered two tablets of Tylenol (medication to treat mild pain).
Review of Resident CL1's clinical record failed to reveal the resident was thoroughly assessed after complaining of a headache. The resident's blood pressure and blood sugar were not assessed. A pulse rate (81 BPM) and respirations (18) were assessed on September 23, 2024, at 3:40 p.m.
Review of Resident CL1's MAR revealed Resident CL1 was administered with Insulin Aspart 70/30 25 units on September 23, 2024, at 5:00 p.m.
Review of Resident CL1's meal consumption revealed the following: September 23, 2024, at 8:00 a.m., (25% eaten); noon (50% eaten), and 8:23 p.m., (25% eaten).
Review of Resident CL1's nursing progress notes dated September 23, 2024, at 10:46 p.m., revealed around 8:00 p.m., the resident's family came and observed the resident with eyes closed and not responding. The nursing supervisor was notified, 911 was called and the resident was sent to the emergency room.
Review of Resident CL1's hospital transfer form dated September 23, 2024, revealed the reason for the transfer was altered mental status, vitals as follows: Blood pressure 146/57 mmHg; pulse 75 BPM; respirations 18/min.; temperature 97.7 F; and Spo2 was 91%. Records did not reveal blood sugar was checked.
Review of Resident CL1's hospital records and emergency provider notes dated September 23, 2024, revealed "patient presents to the ED (Emergency Department) for evaluation of altered mental status. On arrival, the patient is lethargic and unable to answer any questions. Per medics, blood sugar was 59. Additional hospital records review and ED clinical impression revealed initial fingerstick glucose performed on arrival showing blood sugar to be 30, Dextrose (medication used to treat low blood sugar) was given. The patient was also found to be with hypokalemia (low potassium level). The patient was admitted with Altered Mantal Status, Hypoglycemia, and Hypokalemia. Hospital blood work done on September 23, 2024, revealed a blood glucose level of 25 mg/dl."
The above information was conveyed to the Director of Nursing on October 7, 2024, at 1:00 p.m.
The facility failed to assess, monitor, and provide necessary treatment to Resident CL1's for Diabetes resulting in hospitalization for low blood sugar levels.
28 Pa. Code: 211.12(d)(5) Nursing Services
Previously cited 7/1/24
28 Pa. Code: 211.12 (d)(1)(3) Nursing Services
Previously cited 7/1/24
| | Plan of Correction - To be completed: 11/14/2024
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Resident CL1 is discharged from the facility.
Current new admissions with a diagnosis of Diabetes will be reviewed during clinical meeting to verify facility staff clarified admission orders with the physician and blood glucose monitoring has been ordered as per the hospital discharge instructions, or monitoring for hypoglycemia is in place. Current residents will be reviewed during clinical meetings to verify an assessment and blood glucose has been documented for diabetic residents with symptoms of hypoglycemia prior to the transfer to the hospital.
The Nurse Practice Educator or designee will re-inservice licensed nurses on the Hypoglycemic Procedure as well as the Change of Condition with a focus on diabetic management.
The Director of Nursing or designee will conduct weekly audits x 4, then monthly x 2 of new admissions to verify staff clarified admission orders with the physician and if blood glucose monitoring has been ordered as per the hospital discharge instructions, and an assessment and blood glucose has been documented for diabetic residents with symptoms of hypoglycemia prior to transferring to the hospital.
The DON/designee will review the findings of the audits during the QAPI meetings x3 months.
|
|
