PEMBROKE, NC- PEMBROKE CENTER

Diabetic Ketoacidosis

Based on record review and Physician and staff interviews the facility failed to provide care for a diabetic by failing to obtain and monitor blood sugar (BS) levels for 1 of 1 residents (Resident #171) which resulted in the resident being admitted to the hospital for Diabetic Ketoacidosis (DKA). DKA is the formation of a toxic chemical in the blood caused by prolonged high blood sugar which can be life threatening. Resident #171 was also admitted to the hospital with hyperosmolar hyperglycemia (a complication from high blood sugar for a long period of time that causes severe dehydration and confusion).

Immediate Jeopardy began on 02/22/21 when Resident #171 was readmitted to the facility with sliding scale insulin orders and parameters to administer insulin but no orders directing the monitoring of Resident #171’s blood sugar and no sliding scale insulin was administered.

The Medication Administration Record (MAR) for 02/22/21-03/23/21 revealed no documentation that BS monitoring had been completed or that any sliding scale insulin (SSI) had been administered.

The Physician’s Progress Note dated 02/23/21 revealed Resident #171 was being seen by the physician after readmission to the facility from the hospital. The plan was to monitor Resident #171’s BS and adjust the medication as indicated.

The Change in Condition Evaluation dated 03/24/21, and documented by Nurse #6, revealed that Resident #171 experienced a hyperglycemic (high BS) episode that started the morning of 03/24/21. There were no mental or functional status changes observed. The physician was notified and an order to give 20 units of insulin with fluids was received. Hourly BS testing was also to be done. The 03/24/21 MAR revealed there was no documentation that 20 units of insulin was administered to Resident #171 prior to transfer to the Emergency Department (ED).

In a telephone interview on 05/16/21 at 2:31 PM Nurse #6, who was assigned to care for Resident #171 when he was sent to the hospital on 03/24/21, stated she could not remember what was going on with Resident #171 on the morning of 03/24/21. She indicated that something did not seem right with the resident and that she asked another nurse to come into the room. Nurse #6 indicated that she thought it was Nurse #3 who came into the room and suggested she check Resident #171’s BS. She stated that she had not received any information in report that Resident #171 was acting any differently than he usually did. Nurse #6 stated she injected 20 units of whatever type of insulin was in the medication cart for him to the resident. She indicated she did not document that the insulin was administered because she thought someone else was going to do that as she was busy. Nurse #6 stated she took BS readings several times that morning and it kept reading high instead of providing a number. She indicated that the family decided to send Resident #171 to the hospital after being informed about what was going on. Nurse #6 stated that in order to tell how much SSI to administer to a resident she would need to know what their BS was. She indicated that to know what the BS reading was she would have to test the resident’s blood. Nurse #6 stated that BS should be checked as often as the order said and if it was not listed then the physician should be called, and the order clarified. She indicated that she had not called the physician to clarify the SSI order.

U.T.I Medication Issue

A progress note dated 04/20/21 at 1:57 PM revealed Resident (#64) was seen by the physician for an acute visit with new orders given for a urinalysis (UA) with culture and sensitivity (C&S) due to complaints of dysuria (painful or difficult urination).

A progress note dated 04/21/21 at 5:30 AM revealed an in and out catheterization was performed for urine specimen collection.

The lab analysis report for Resident #64’s urine sample revealed the specimen was received by the laboratory on 04/21/21 and the final report was verified by the lab and sent to the facility on [DATE]. The urine culture results revealed there were greater than 100,000 CFU/ml (Colony Forming Units per milliliters) of klebsiella pneumoniae indicating a positive UTI. The organism was shown to be sensitive to Amoxicillin Clavulanate (Augmentin) among other antibiotics.

No physician orders were written from 04/21/21 through 04/27/21 to treat the residents (#64) UTI.

A follow up phone interview was conducted on 05/19/21 at 10:45 AM with the DON. She stated the lab picks up the urine specimen after collection, and the results were faxed to the facility. She stated staff should have followed up with the lab sooner. She reported the medication was not available in the facility on 04/28/21 and therefore had to wait for it to be sent from the Pharmacy which was why the first dose was not administered to Resident #64 until 04/30/21.

Fall Risks

The Care Plan created 05/04/16 revealed that Resident #47 was at risk for falls and was revised on 05/11/21 to show that Resident #47 had a fall without injury on 05/09/21. The Care Plan contained an intervention of a fall mat at the bedside that was revised on 02/26/21.

The eINTERACT SBAR Summary for Providers dated 05/09/21 at 10:15 PM and completed by Nurse #4 revealed that Resident #47 had a fall from the bed onto the floor and received a skin tear. Resident #47 was lying on her right side between the bed and the window. Resident #47 was assessed by the nurse and placed back in bed. The physician was notified and requested Resident #47 be monitored.

In an observation on 05/10/21 at 3:17 PM the right side of Resident #47’s bed was against the wall and there were no fall mats on either side of the bed. In an observation on 05/11/21 at 5:41 PM the right side of Resident #47’s bed was against the wall and there were no fall mats on either side of the bed.

The May 2021 Treatment Administration Record (TAR) revealed that the fall mat at bedside every shift order had been initialed as administered (completed) on all three shifts on 05/10/21, 05/11/21, and 05/12/21. 

In an observation and interview on 05/12/21 at 10:23 AM the right side of Resident #47’s bed was against the wall and there were no fall mats on either side of the bed. The Hospice Aide stated that she did not recall seeing fall mats on the floor beside Resident #47’s bed before. She indicated that Resident #47 had bolsters on her bed but that she was still able to move enough to fall out of the bed. She indicated that she was not in the facility when Resident #47 fell on [DATE] but she did know that there were no fall mats when she worked with the resident on 05/10/21 during the day.