**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #3) reviewed for medication errors, the facility failed to prevent a significant medication error by failing to accurately transcribe Providers order's and verify Provider's orders for a resident readmitted to the facility. This failure resulted in the finding of Immediate Jeopardy. The findings include: Resident #3 was admitted to the facility in September of 2024 with diagnoses including type 2 diabetes mellitus, Parkinson's disease, anxiety disorder and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had moderately impaired cognition (Brief Mental Interview for Mental Status (BIMS) score of 12) and required supervision assistance with transfers and moderate assistance with bed mobility. The Resident Care Plan (RCP) dated 1/7/25 identified that Resident #3 had diabetes mellitus. Interventions included to monitor/document/report as needed any signs and symptoms of hypoglycemia to include sweating, tremors, increased heart rate (tachycardia), change in skin color, nervousness, confusion, slurred speech, lack of coordination and staggering gait and diabetes medication to be administered as ordered by physician and staff to monitor/document for side effects and effectiveness. Review of facility Reportable Event (RE) dated 3/6/25 identified a medication transcription error upon readmission to the facility, from the hospital, on 3/2/25. The report identified that Levemir insulin 5 units was renewed (mechanism within the electronic medical record (EMR) which allows the selection of previously discontinued orders to be reactivated, as previously ordered, but with a current start date. The discontinued order section of the EMR contains a select all option, which will renew all previously discontinued orders within the EMR, if selected) within the EMR, but not listed as an active order on hospital discharge documents and was not ordered by the readmitting provider (NP #1). Review of the hospital discharge documents dated 3/2/25 identified Resident #3 was admitted to the hospital from [DATE] through 3/2/25 and contained no documentation that Levemir insulin was administered throughout the hospital admission or should be started upon discharge. Medications that the discharge documents identified as stopped, during the hospital admission, included tradjenta (oral anti-diabetic medication) 5 milligrams (mg) tablet, metformin (oral anti-diabetic medication) 1000 mg tablet, and metformin 500 mg tablet. A physician's order dated 3/2/25 directed to administer Levemir insulin subcutaneous (under the skin) solution 100 units (u) per milliliter (mL), inject 5 units subcutaneously one time a day for type 2 diabetes mellitus and to hold for a blood sugar less than 80. Review of the facility Medication Administration Record (MAR) for March 2025 identified an order for Levemir insulin 5u daily was administered at 9:00 AM on 3/3/25 (by LPN #3), 3/4/25 (by LPN #2), and 3/5/25 (by LPN #1). Further review of the clinical record identified that an order directing Levemir insulin subcutaneous solution 100 u per mL, inject 5 units subcutaneously one time a day for type 2 diabetes mellitus and to hold for a blood sugar less than 80, was initially ordered at the facility on 3/27/24 and was discontinued at the facility on 5/16/24. Review of the MAR for March 2025 identified an order for tradjenta 5 mg once daily had a start date of 10/10/24 and was administered at 5:00 PM on 3/2/25 (by LPN #4) and subsequently discontinued at 5:45 PM. Review of the MAR for March 2025 identified an order for metformin 500 mg twice daily had a start date of 10/10/24 and was administered at 5:00 PM on 3/2/25 (by LPN #4) and subsequently discontinued at 5:45 PM. Review of the Order Audit Report for Resident #3 identified the DNS discontinued the tradjenta 5 mg and metformin 500 mg orders on 3/2/25 at 5:45 PM, after the medications were administered at 5:00 PM. Review of Nurse Practitioner (NP) visit notes dated 3/3/25 and 3/4/25 failed to identify the four (4) transcription errors. Review of the clinical record failed to identify that blood sugars were obtained from 3/2/25 through 3/5/25. A Nurse's note dated 3/5/25 at 10:22 PM identified that RN #3 was notified Resident #3 was experiencing a change in condition, and was observed in bed leaning to the left, flailing his/her arms and legs around. The note identified that staff were unable to obtain a blood pressure due to Resident #3's movement, that Resident #3 was alert but unable to answer questions or produce any noise, and both pupils were nonresponsive to light. NP #1 was notified and directed RN #3 inquire with Resident #3 ' s family on transfer to the Emergency Department (ED) for evaluation. The note identified that Resident #3's family sent a relative to see Resident #3, and once the relative arrived, they demanded Resident #3 be sent to the ED. Emergency Medical Services (EMS) were called and Resident #3 was transferred to the ED for evaluation. Review of the Prehospital Care Report (ambulance run sheet) dated 3/5/25 identified that EMS arrived at the facility at 6:30 PM and Resident #3 was observed in bed, moving around like he/she was in pain but unresponsive to commands and questions. The report identified LPN #4 stated she last saw Resident #3 around 4:00 PM and when she entered Resident #3's room around 6:00 PM, she found Resident #3 in the above-mentioned state, and stated Resident #3 was normally alert and oriented so this was not his/her normal behavior. The report identified that clinical paperwork was reviewed and identified Resident #3 had a diabetic history. LPN #4 was asked if she obtained Resident #3's blood sugar level, and she reported she had not. The report identified Resident #3's blood sugar was obtained with a result of 29, Resident #3 was administered a 250 mg bag of D10 (dextrose) in route to the hospital, responded well, and the involuntary body movements subsided. Review of the hospital ED note dated 3/5/25 at 7:24 PM identified that Resident #3 presented at the ED for hypoglycemia (low blood sugar) and was found to have a blood sugar of 29 (critically low level) by EMS and dextrose (sugar) was given on route to the hospital. The note identified that Resident #3 became more responsive and his/her sugar level improved. The note further identified that blood work and an ECG (electrocardiogram) were obtained and resulted within normal limits and Resident #3 was discharged back to the facility on 3/6/25. Review of RN #2's statement dated 3/6/25 identified that, as an agency nurse, she was instructed for the readmission process, to discontinue all medication orders and then renew the medication orders so the pharmacy was alerted that the resident returned to the facility. The statement identified RN #2 renewed all of Resident #3's previously discontinued medication orders during the readmission process, including the Levemir insulin. Interview with RN #2 on 3/19/25 at 11:49 AM identified she was the nursing supervisor on 3/2/25 responsible for readmitting Resident #3 to the facility. RN #2 identified the DNS instructed her to discontinue all active EMR orders from prior to the hospitalization and then renew all of the discontinued EMR orders. RN #2 reported that after discontinuing and renewing all of the EMR orders, she reviewed the hospital discharge documents with NP #1 and entered new orders subsequent to the hospitalization. RN #2 identified that she then signed and activated all of the orders without the benefit of verifying the orders she was signing and activating for accuracy. She identified that she inadvertently renewed previously discontinued EMR orders to include Levemir insulin which was discontinued nearly a year prior to the hospitalization and tradjenta, metformin and Seroquel orders which were to be stopped according to the hospital discharge documents. RN #2 identified that she should have verified the orders before signing and activating them to ensure accuracy. Interview with NP #1 on 3/19/25 at 12:02 PM identified that when there is a new admission, the RN Supervisor sends her a copy of the discharge documents and medication list which she reviews and approves as appropriate. She identified that on 3/2/25, the hospital discharge documents directed to stop tradjenta, metformin and Seroquel and further identified RN #2 never reported an order for Levemir insulin. She identified when she saw Resident #3 on 3/3/25 and 3/4/25 she did not review the active medication list in the EMR as she should have. She identified that Resident #3 receiving Levemir insulin was a significant medication error, which could have led to seizures and/or death if EMS did not arrive when they did. NP #1 identified that a third shift nurse is supposed to verify the orders for accuracy, which did not occur, and could have identified the error. NP #1 identified that for all residents who are administered insulin, a standard of practice and facility policy, is that a blood sugar is obtained prior to administration, and the Levemir insulin order directed to hold the Levemir insulin for a blood sugar less than 80, which could have prevented the hypoglycemic episode. Interview with LPN #1 on 3/19/25 at 12:35 PM identified that on 3/5/25 she administered Levemir insulin to Resident #3 without first obtaining his/her blood sugar although she knew obtaining a blood sugar was required. She further identified that she did not completely read the order. Interview with RN #3 (Nursing Supervisor) on 3/19/25 at 1:20 PM identified that on 3/5/25 between 6:00 PM and 7:00 PM, LPN #4 reported Resident #3 was unresponsive. RN #3 indicated she assessed Resident #3 and thought he/she may have had a stroke, then further indicated she should have obtained a blood sugar but did not think to do so. Interview with LPN #4 on 3/19/25 at 2:34 PM identified that on 3/2/25, RN #2 notified her Resident #3's readmission orders were complete and she (LPN #4) administered all medications reflected on the EMR. LPN #4 identified no one instructed her to verify the readmission orders. LPN #4 identified that on 3/5/25, sometime after dinner, Resident #3 had a change in condition, she immediately notified RN #3, and they attempted to obtain vital signs but were unsuccessful due to Resident #3's uncontrolled body movements. She identified she was unaware Resident #3 received Levemir insulin since readmission to the facility, but was aware that Resident #3 was diabetic and received oral anti diabetic medications. LPN #4 identified she did not think to check Resident #3 ' s blood sugar when the change in condition was identified. Interview with the DNS on 3/19/25 at 2:14 PM identified that RN #2 should have verified the readmission orders for Resident #3 prior to activating them, should have instructed LPN #4 (3:00 PM to 11:00 PM charge nurse on 3/2/25) to verify the orders and LPN #5 should have verified the readmission orders on third shift (11:00 PM to 7:00 AM). The DNS identified that LPN #1, LPN #2 and LPN #3 should have obtained Resident #3 ' s blood sugar prior to administering the Levemir insulin on 3/3/25, 3/4/25 and 3/5/25 according to the provider's order instructions and that LPN #4 or RN #3 should have checked Resident #3 ' s blood sugar on 3/5/25 when a change in condition was identified. Although attempted, interviews with MD #1, LPN #2 , LPN #3 and LPN #5 were not obtained. Review of the Agency Orientation Acknowledgement packet provided by the DNS identified a table of contents including policies, in part, for Care Plans/Resident Care Cards, Documentation and paper/EMR plan of care. The packet failed to identify the admission/readmission process to include order transcription and medication reconciliation. The Agency Orientation Acknowledgement was manually signed by RN #2 on 5/17/24 and electronically signed by RN #3 on 3/5/25 at 12:36 AM. Review of the Insulin Administration policy (undated) directed, in part, that the type of insulin, dosage requirements, strength and method of administration must be verified before administration, to ensure that it corresponds with the order on the medication sheet and the physician's order. The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin. Document the resident's blood glucose result, as ordered. Review of the Diabetes- Clinical Protocol policy (undated) directed, in part, that the risk for hypoglycemia should be considered in any treatment plan, as it is a significant and high-risk complication of treatment. For the resident receiving insulin who is well controlled: monitor blood glucose levels twice daily if on insulin. Review of the Adverse Consequences and Medication Errors policy (undated) directed, in part, that the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. Review of the Telephone/Verbal orders policy (undated) directed, in part, that orders must be entered by the person receiving the orders and telephone orders must be countersigned by the physician during his or her next visit. Although requested, policies on Medication Transcription and Medication Reconciliation were not provided. The Immediate Jeopardy template was presented to the Administrator by the State Agency on 3/20/25 at 1:30 PM. The facility immediately initiated a removal plan which included ensuring Resident #3 was receiving all medications according to Provider order, education for all nursing staff to include medication reconciliation and diabetes management, auditing of all residents prescribed insulin and auditing of all readmission orders. The removal plan was verified and accepted by the State Agency during an on-site visit on 3/20/25 at 5:21 PM and the Immediate Jeopardy was removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interviews for one (1) of three (3) residents (Resident #1), reviewed for diabetic management, the facility failed to notify the physician of a decreased blood glucose measurement prior to administering a dose of insulin (that was based on a higher blood glucose result) resulting in Resident #1 being found unresponsive approximately 3 hours later with a blood glucose level of 28 (a normal blood glucose level is between 70 and 120). Additionally, the facility failed to ensure emergency glucagon was readily available for a resident who was unresponsive and experiencing a hypoglycemic event. These failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included type 2 diabetes mellitus with long term use of insulin. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact cognition, required minimum assistance with activities of daily living, and received insulin injections daily. The Resident Care Plan (RCP) dated 3/13/2024 identified Resident #1 is at risk for complication related to diabetes mellitus as evidenced by hypo/hyperglycemia with interventions that directed to monitor for signs/symptoms of hypo/hyperglycemia, administer medications as ordered, assess, monitor, record, and report any changes, concerns to MD and family/conservator, and to monitor diet. The physician orders dated 4/1/24 directed to administer Humalog KwikPen (U-100) Insulin 100 units/milliliter (a fast acting insulin), subcutaneous (under the skin). Inject the insulin by subcutaneous route once daily in accordance to the sliding scale every day at 6:00 AM. The sliding scale directed to administer 3 units of Humalog for a blood sugar of 250 to 300, to administer 5 units of Humalog for a blood sugar of 301 to 350, and to administer 7 units of Humalog for a blood sugar of 351 to 450, and to call the physician for a blood sugar greater that 450. Review of the nursing progress note dated 4/07/24 at 6:00 AM written by RN #1 identified Resident #1's blood glucose level was 420, the physician was made aware, and a new order for 10 units Humalog was obtained as a one time dose to be administered after breakfast. A nurse's note dated 4/07/2024 at 1:37 PM written by RN #2 identified Resident #1's blood glucose result (finger stick) was re-checked at 9:00 AM with a result of 269, prior to administering new order of one-time dose of Humalog Insulin (10 units). The one-time Humalog dose was administered as ordered at 9:00 AM. At approximately 12:10 PM, Resident #1 was unresponsive, diaphoretic with twitching and jerky movements. The blood glucose level was obtained and resulted at 28. Resident #1 unable to take oral intake. A call was placed to Emergency Medical Services (EMS) who arrived at approximately 12:19 PM. A dose of glucose was administered by EMS personnel prior to transfer to hospital. All responsible parties were notified. Review of the EMS run sheet dated 4/07/2024 identified that the facility called for emergency services at 12:06 PM and arrived at Resident #1's bedside at 12:15 PM. Resident #1's blood glucose level was 18 mg/dl upon arrival, an intravenous access was obtained, and Resident #1 received 250 milliliters of 10 % Dextrose (a sugar solution) intravenously. A repeat blood glucose level was 170 prior to transport to the hospital. Interview with RN #2 on 4/22/2024 at 11:10 AM identified she was the RN supervisor and Resident #1's charge nurse for the 7:00 AM to 3:00 PM on 4/07/24. RN #2 identified that during 11:00 PM to 7:00 AM shift report from RN #1 it was identified that Resident #1's blood glucose level was 420, and Physician #1 was notified and a one-time physician's order was received for 10 units of Humalog insulin to be administered after breakfast. RN #2 obtained a blood glucose level at 9:00 AM, that resulted at 269. RN #2 indicated she did not question the physician order (although she had obtained a lower blood result) as she was not aware that Resident #1 had a sliding scale, and she had a physician's order to follow, so she administered the 10 units of Humalog insulin to Resident #1. RN #2 identified at approximately 12:10 PM, Resident #1 was unresponsive, making twitching/jerking movements, and was diaphoretic with a blood sugar of 28. RN #2 called 911 and attempted to locate the emergency glucagon (an injectable medication used to treat low blood sugar in an emergency), but was unable to locate it, despite looking in the code cart, emergency box, medication room, and medication cart. EMS personnel arrived at Resident #1's bedside at approximately 12:19 PM and took over care. RN #2 identified that she was not aware where the glucagon was stored in the facility, however, subsequent to Resident #1 leaving to go to the hospital the glucagon was found on another unit, located on the second floor (Resident #1 resides on the 1st floor). Interview with Physician #1 on 4/22/2024 at 11:30 AM identified Resident #1's hypoglycemic event was likely related to receiving the 10 units of Humalog Insulin he/she received on 4/7/2024 at 9:00 AM for the blood glucose of 269, as the 10 units of Humalog insulin was intended for a blood sugar of 420. Physician #1 identified he would have expected to be notified of the new blood glucose of 269 that was obtained at 9:00 AM, as he would have given new orders to address the new, lower blood sugar. Physician #1 identified that he believed there was always emergency medications readily available, such as glucagon, and his expectation for nursing staff would be to administer glucagon as fast and as quickly as possible to prevent any adverse events. Interview with Director of Nurses (DON) on 4/22/2024 at 10:00 AM identified RN #2 should have notified Physician #1 after obtaining the new blood glucose level of 269, and should have administered glucagon during the hypoglycemic episode, as she believed RN #2 knew where the medication was located but failed to administer it. The DON further identified that is was unclear why RN #1 called the physician on 4/7/24 when the sliding scale insulin coverage included blood sugars up to 450, subsequently, RN #1 received additional education to include reviewing physician orders prior to notifying the physician about a blood sugar and to communicate what current interventions were in place to aid the physician with decision making. Multiple attempts to contact RN #1 were unsuccessful Review of the Insulin Reaction-Medical Emergencies Policy (undated) directed to remain with and reassure the individual, and call for assistance. Take vital signs. If conscious, give whole milk. Utilize blood glucose monitoring equipment located in each medication room. Notify the physician and responsible party. prepare a W-10 for any emergency room transfers, if ordered by physician. Document as appropriate in the clinical record. If a reportable event, follow the policy and procedure for reporting. The policy failed to identify guidance on what to do when a resident is unconscious and unable to take oral intake.