BORGER, TX- BORGER HEALTHCARE CENTER

An Immediate Jeopardy was identified on [DATE] at 4:30 PM as having occurred from [DATE] – [DATE]. However, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of isolated because the facility had not had time to monitor their plan of removal for effectiveness. This failure placed current and future diabetic residents at risk for elevated blood sugars, coma, and death.

During an interview with LVN B on [DATE] at 11:21 AM she said there were no blood sugar checks done; there were no orders for insulin or blood sugar checks.

During an interview with LVN A on [DATE] at 11:26 AM she said Resident #1 was admitted Thursday, [DATE] and she admitted him. She said she got report from the nurse at the hospital and was told his primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was told they treated him at the hospital for [CONDITION(S)] and that they got it under control. She said they didn’t need to do finger sticks to check his blood sugar because he had a device in his arm for checking his blood glucose levels. She was told by the nurse at the hospital to get with his doctor and decide if they wanted to use this device or not. She never did . She called the NP and went over his list of meds from the hospital. She said his insulin was listed as new/continue but also on the discontinue list. She took that as to discontinue his insulin and she said that was what she relayed to the NP. She said she failed to look at the whole dosage and just looked at the medicine listed. She didn’t see that it said to start 20 units and down at the bottom of the list it said discontinue 9 units. He was previously on 9 units and was ordered to take 20 units. She said she made a mistake when she looked at the orders wrong. She said because she told the NP the insulin was discontinued, the NP said they would see how he does and didn’t order to do the finger sticks to check his blood sugar. The NP did order to get his Hemoglobin A1C labs, however this was never done.

During an interview with the Director of Nursing on [DATE] at 2:15 PM she said that no lab work was done for Resident #1, including his hemoglobin A1C that was ordered on [DATE] when he was admitted . She said their scheduled lab days were Monday – Thursday. He would have had his lab done on [DATE] but he went to the hospital on [DATE]. During a simultaneous interview with LVN A, both where asked who wrote a note on Resident #1’s Discharge Instructions from the hospital that read, Is DM but no FS rt now. At first LVN A denied writing the note but after closer inspection and the DON saying it looked like her handwriting, LVN A said she wrote the handwritten note. When asked what was said and what it meant, she said, Is diabetic but no finger sticks right now. DON said she usually double checks the orders of the newly admitted residents, but she didn’t work again until Monday, [DATE]. She said normally, if she doesn’t review the orders, then the ADON would review them. She said the ADON didn’t review them either because she was working the night shift as a floor nurse. When asked what could happen to a person with diabetes if they were supposed to have insulin every day but don’t get it for 3 days, both said a person with diabetes could go into a diabetic coma. When asked if this situation could have been prevented, DON said it could have been prevented and should have been found within 24 hours if someone had reviewed Resident #1’s admission paperwork and orders.

During an interview with Nurse Practitioner  on [DATE] at 2:55 pm, she said she expects the nurses to give her the correct information from the hospital’s discharge orders. She said she remembered ordering Resident #1’s hemoglobin A1C and that lab work should have been done the next day, not wait until Monday on their routine lab days.

During an interview with Director of Nursing on [DATE] at 3:40 pm, she said they didn’t do any finger stick blood sugar checks on Resident #1 because LVN A said the hospital wasn’t doing them, so they didn’t do them at the nursing facility either. She said Resident #1 had a device in his arm that checked his blood sugars, and it was read from an unknown agency. They didn’t know where that information was sent, and they didn’t have access to that information. DON said they should have been finding out what his glucose levels were.

During a follow up interview on [DATE] at 9:07 AM, ADM said they didn’t make any new policies, they went over existing policies that were already in place, they just weren’t being followed.