State Findings:
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care for 2 of 11 residents reviewed for sufficient nursing staff. (Resident #s 2 and 5)
The facility did not accurately enter physician’s orders [REDACTED].#2’s blood sugar and administration of insulin and did not reference physician orders [REDACTED]. Resident #2’s physician order [REDACTED].#2’s blood sugar was at or below 250 milligrams per deciliter. (mg/dl) Resident #2’s blood sugar was not checked hourly and RN B administered 3 units of insulin to Resident #2 for a blood sugar of 158 mg/dl. Resident #2’s blood sugar dropped to a critically low level of 23 mg/dl requiring emergency intervention and hospitalization. LVN C did not know how to access Resident #5’s physician orders. He administered medications from Resident #5’s MAR indicated [REDACTED]
An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm due to the facility’s need to complete in-service training and evaluate the effectiveness of the corrective systems.
This failure could place residents who received insulin at risk for having critically low blood sugar levels resulting in harm or death.
During an interview on [DATE] at 3:00 p.m., the DON said on [DATE] the nursing staff should have been checking Resident #2’s blood sugar every hour. She said Resident #2 should not have received any insulin after her blood sugar was 250mg/ml or less. The DON said when RN B administered 3 units of insulin to Resident #2 for a blood sugar of 158 mg/dl it was a medication error. She said they were not aware of the medication error until identified by investigators on [DATE]. The DON said she reviewed Resident #2’s records after she was hospitalized for [REDACTED]. The DON said the order for glucose monitoring received on [DATE] by LVN A was not entered correctly in the record.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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