**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility neglected to ensure necessary care and services were provided by ensuring nurses coordinated with physicians to provide proper provision of care for 1 of 1 resident reviewed for insulin-dependent Diabetes Mellitus with an insulin pump, of a total sample of 5 residents, (#1). The facility failed to recognize the critical need for insulin orders and blood glucose finger sticks upon admission and failed to implement physician ordered finger stick blood glucose monitoring after it was prescribed. These combined failures in care coordination resulted in a lack of proper blood glucose monitoring and treatment for eight days, during which the resident developed Diabetic Ketoacidosis (DKA), a life-threatening condition. The resident required emergency 911 transfer to the hospital and re-hospitalization with Intensive Care Unit (ICU) level care, for 5 days. DKA is a life-threatening complication that affects people with diabetes and requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates an emergency medical situation. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin. Without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. DKA is diagnosed if your blood glucose level is above 250 milligrams/deciliter (mg/dL), your blood is acidic, you have ketone (acid molecules) in your urine or blood, and your blood bicarbonate level is lower than 18 milliequivalents/ liter. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Most pumps are small, computerized devices that are roughly the size of a juice box or a deck of cards. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25). Resident #1 was hospitalized for five days requiring critical care in the ICU, and an intravenous (IV) insulin drip. She returned to the facility on 5/23/25 for continued recovery and therapy until 6/18/25, when the resident had a planned discharged to an inpatient rehabilitation hospital. From admission on [DATE], the facility's nurses did not coordinate vital care needs with the on-call provider to ensure finger stick blood glucose monitoring and insulin orders were implemented on admission. On 5/13/25, the Interdisciplinary Team (IDT) reviewed resident #1's hospital records and admission orders. The IDT failed to recognize finger stick and insulin orders were missing for a high-risk resident with an insulin pump. On 5/14/25, the attending physician and Advanced Practice Nurse Practitioner (APRN) jointly assessed resident #1. On 5/15/25, the attending physician entered an order for finger stick blood glucose testing in the Electronic Medical Record (EMR). Nurses failed to properly finalize the order to link to the Medication Administration Record (MAR) in which prompts notified nurses to perform the tests. The resident's primary care providers did not recognize test results were missing that if implemented, would have detected resident #1's unstable blood glucose levels and prevented complications, worsening of condition, and mitigated the risk of serious injury/impairment/death with the implementation of appropriate interventions. Eight days after resident #1 arrived at the facility, on Monday, 5/19/25, a nurse observed the resident sitting on the floor in her room. After performing two finger stick blood glucose tests with readings of high (exceeded device measurement parameters), physician's orders were obtained to transport the resident to the hospital via 911 Emergency Medical Services (EMS) for dangerously high blood sugar. The facility's neglect to recognize and implement proper provision of care and services for a high-risk resident with type I Diabetes Mellitus and an insulin pump contributed to the destabilization of resident #1's medical conditions and placed all residents at risk for neglect and serious injury/impairment/death. For eight days, the facility was unaware resident #1 was missing critical clinical monitoring and insulin until the resident's condition worsened with weakness and altered mental status and she fell. This failure resulted in Immediate Jeopardy which began on 5/12/25.Findings: Cross reference F635 and F726 Review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility from an acute care hospital on 5/12/25 with diagnoses that included: acute metabolic encephalopathy (brain dysfunction), diabetes mellitus, hyperglycemia (high blood sugar), other seizures, pneumonia, hypotension (low blood pressure), dependence on renal (kidney) dialysis, and history of venous thrombosis/embolism (blood clot). The Minimum Data Set (MDS) 5-day Assessment with an Assessment Reference Date of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. The assessment noted resident #1 had an altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered during the lookback period but did receive high-risk opioid and anticonvulsant medications. The resident received hemodialysis before admission and during the stay. Resident #1's pre-admission clinical documents faxed from the hospital Case Manager on 5/08/25 for the facility's pre-admission review and acceptance noted the resident was admitted to the hospital on [DATE] for multiple episodes of loss of consciousness, and possible seizure. The History of Present Illness (HPI) section of the physician's notes indicated the resident's family reported that no recent doses of medications were missed. The documents detailed that hyperglycemia was treated with sliding scale insulin and finger stick blood glucose monitoring. The notes showed her home medications included Omnipod 5 Dexg7g6 Pods (Gen5) 1 dose daily via insulin pump, Lantus Insulin 4 Units (IU) subcutaneous (SQ) daily, and Lispro Insulin 2 IU SQ three times daily before meals. The Agency for Healthcare Administration (AHCA) Form 5000-3008 signed by the hospital provider dated 5/12/25 documented resident #1's Discharge Summary and Discharge Medication List reports were attached. The hospital discharge physician's ordered medication list dated 5/12/25, documented orders to continue home medications which included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose SQ daily; Insulin Glargine (Lantus), 4 IU SQ daily; and Insulin Lispro, 2 IU SQ three times daily before meals. Review of the admission Packet sent with resident #1 from the hospital on 5/12/25 for facility admission revealed physician's ordered discharge medications included, New: Oxycodone immediate release 10 Milligrams (MG) every 4 hours as needed for 3 days, Tylenol 650 MG every 6 hours as needed, Minoxidil 60 Gram Foam, topical (on skin) daily. The medication list directed the resident continue taking the following medications: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen5), 1 cartridge, 1 dose SQ daily, Lantus Insulin 4 IU SQ daily, and Lispro Insulin 2 IU SQ three times daily before meals, Creon 36,000 IU three times daily, Divalproex Sodium 500 MG twice daily, Lacosamide 100 MG twice daily, Levothyroxine 50 Micrograms (MCG) once daily, Midodrine 10 MG three times daily, Gabapentin 300 MG at bedtime, In a telephone interview on 7/29/25 at 10:06 AM, the Director of Admissions explained she received hospital referrals and was responsible for screening/accepting potential admissions to the facility. She said she did not have any clinical or medical professional credentials and sent off any potentially complicated or special clinical needs referrals to the facility Director of Nursing (DON) or designee and the Corporate Office for further review and approvals. She recalled she received resident #1's first referral via facsimile and didn't see anything that required further approval, so she independently accepted the resident for admission. She said she had worked at the facility for approximately a year and a half and didn't recall any previously admitted residents with an insulin pump and stated, I don't necessarily consider that something we can't handle. On 7/29/25 at 10:40 AM, the DON recalled there was not a pre-admission clinical review completed for resident #1's 1st admission, and the facility had not previously accepted any residents with an insulin pump in the last few years since she worked at the facility. The DON said she didn't think the Director of Admissions was aware the resident had an insulin pump and if she had known, additional clinical review was required. In a telephone interview with APRN D, the DON, and the Assistant Director of Nursing (ADON) on 7/28/25 at 12:24 PM, APRN D said insulin pumps could not be administered by nurses at the facility, and they required special monitoring with an outpatient specialist. The APRN could not recall any other residents with an insulin pump at the facility prior to resident #1. On 7/31/25 at 9:24 AM, the Director of Operations explained the facility did not have a written policy for what conditions, devices, etc. the facility did or did not accept. She said there were practices the facility followed that dictated when additional clinical review was required. Resident #1's Care Plan Report showed a care plan was initiated on 5/13/25 and revised on 6/03/25 for Activities of Daily Living (ADLs) self-care performance deficit related to diabetes mellitus type I, history of recent DKA, encephalopathy, history of acute kidney injury, dependence on dialysis, chronic hypotension, and asthma. Interventions included for nurses to monitor/document/report any changes or declines in function. Other care plans included on 5/13/25 diabetes mellitus with a goal for no complications, and interventions for diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms. On 5/13/25 a care plan for risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, hypotension, neuropathy, fall risk score, and fall history was implemented. On 5/13/25 a care plan for pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis, altered respiratory status was begun and on 5/16/25 a care plan related to adverse effects of high-risk medication monitoring, risk for pressure injuries. The discharge care plan initiated on 5/13/25 noted the resident wished to be discharged from the facility to community/prior living arrangements (home). There were no care plans addressing resident #1's insulin pump from 5/12/25 to 5/19/25. The May 2025 Medication Administration Report (MAR) showed resident #1's 5/12/25 admission physician's ordered medications included: Bumetanide (diuretic) 2 MG once daily for pneumonia, Gabapentin (anti-convulsant) 300 MG at bedtime for diabetic neuropathy, Levothyroxine 50 Micrograms (MCG) once daily for hypothyroidism, Keppra 1000 MG twice daily for seizures, Lacosamide 100 MG twice daily for seizures, Creon (pancreatic enzymes) 12000-38000 Units (IU) three times daily for dialysis dependence, Midodrine 10 MG three times daily for low blood pressure, and Oxycodone 10 MG every 6 hours as needed for pain. After the resident returned from the hospital on 5/23/25, orders were added that included: Lantus Insulin 4 (IU) once daily for diabetes mellitus increased to 6 IU on 5/31/25, Lispro Insulin 2 IU before meals and changed on 5/24/25 to Novolog Aspart Insulin 2 IU before meals with finger sticks and parameters to notify the APRN for readings of less than 60 mg/dL, or more than 250 mg/dL for diabetes mellitus, and blood glucose finger sticks twice daily with parameters to notify the MD (Medical Doctor) when less than 60 mg/dL, or more than 400 mg/dL. Review of the physician's orders placed on admission to the facility admission on [DATE] included all of medications listed on the hospital physician's discharge medication orders, except for the insulin orders, Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose SQ daily; Insulin Glargine (Lantus), 4 IU SQ daily; and Insulin Lispro, 2 IU SQ three times daily before meals. No finger sticks were ordered. The Nursing admission Evaluation Comprehensive Nursing Assessment completed by Registered Nurse (RN) F on 5/13/25 included a skin assessment with a body map. The image and description did not document areas on resident #1's body with the dialysis catheter or insulin pump. The Special Needs section indicated no catheters or devices were present. The Drug Regimen Review section of the Comprehensive Assessment documented that a review of all medications was performed, no significant medication issues were found, and that the physician was notified on 5/12/25 with no response from the provider noted. The list of medication classes (categories) was marked positive for diabetic medication. A Diabetic Medication Care Plan was checked and initiated with an intervention for diabetic medication as ordered by the physician and to monitor/document for side effects and effectiveness. In a telephone interview with RN F on 7/30/25 at 1:20 PM, the nurse explained the facility practice for new admissions included nurse's review of the hospital's history and physical and discharge medications. She said the documents were sometimes already scanned to the Electronic Medical Record (EMR), and an envelope with photocopies came with the resident from the hospital. She said the normal practice was to notify the on-call provider, provide a report of the resident's medical history, and review the hospital discharge medication orders. The RN recalled resident #1 had an insulin pump and said that finger sticks should have been entered by either herself or the on-coming nurse, as she was a diabetic. She recalled admission orders were obtained from APRN E who wanted the resident's long-acting insulin further evaluated for appropriate orders with the pump. The RN stated, they need finger stick blood sugar orders; I'm not sure if it was an oversight on my part or my co-worker. On 7/29/25 at 10:46 AM, APRN D recalled she participated in the IDT meeting on 5/13/25, the morning after resident #1 was admitted . She explained that APRN E gave admission orders to hold the insulin. She said the resident's hospital records were reviewed which noted the resident had type 1 Diabetes, and it was common knowledge to do finger stick checks for all diabetics with insulin, especially those who were very brittle with an insulin pump. She said pumps could not be managed in a Skilled Nursing Facility (SNF). The APRN said she had assumed there were already orders in place for finger sticks twice a day and she did not recall if the records were checked during the meeting for confirmation. Brittle diabetes is a healthcare term used to describe diabetes that's difficult to manage because of severe swings in blood sugar levels that can cause hospitalization. Swings can cause low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) which mainly affects people with type 1 diabetes, often due to other physician or mental health conditions. Symptoms of low blood sugar include weakness, confusion, clumsiness and seizures. Symptoms/complications of hyperglycemia include fatigue, increased infections including yeast infections, confusion, nausea and vomiting, (retrieved on 8/14/25 from www.myclevelandclinic.org). In a telephone interview on 7/30/25 at 9:15 AM, APRN E explained she was the on-call provider on weekends and Monday nights. The APRN said she followed the hospital physician's discharge medication orders for new admissions, and said she never gave orders to hold newly admitted resident's routine insulin. She did not recall resident #1 specifically, but stated, I would still give orders for blood glucose finger sticks, especially if they had an insulin pump. APRN D's Admit Visit progress note dated 5/13/25 and signed on 5/15/25 listed resident #1's hospital discharge medications but did not include any insulin. The hospital records with laboratory results were noted as reviewed with a blood sugar result of 240 mg/dL. The Diabetes Mellitus diagnosis had comments noted as, blood glucose trends were stable and within normal limits and no medications were taken, but review of finger stick blood glucose monitoring was not mentioned in the report. Nowhere in the note including the Physical Exam section mentioned the insulin pump on resident #1's body although there was at least 60 minutes documented as time spent assessing the resident. The MD (Medical Doctor) History & Physical progress note dated 5/14/25 with 50-94 minutes of assessment duration documented resident #1's most recent comprehensive laboratory results were reviewed with a blood glucose serum level of 244 mg/dL. The Diabetes Mellitus with hyperglycemia diagnosis had comments that noted that no blood glucose finger sticks were available for review and physician's orders were placed for daily blood glucose finger sticks to evaluate insulin. There was no other mention of insulin in the note. In a telephone interview with resident #1's primary care physician on 7/29/25 at 11:20 AM, she explained she expected hospital physician's discharge orders to be followed for medications and said blood glucose finger stick orders were standard protocol for all diabetics with insulin. She explained when she saw resident #1 on 5/14/25 she did not recall there were any insulin orders. The physician recalled the resident's blood glucose was over 200 mg/dL with a diagnosis of diabetes mellitus which needed to be evaluated for insulin coverage. She stated she sent a text message the same day to APRN D with directives to follow up. She said she was unaware up until this interview that the resident used an insulin pump. In an interview on 7/31/25 at 10:02 AM, APRN D recalled on 5/14/25, she jointly assessed resident #1 with the primary care physician. She said on 5/13/25, she ordered labs to check a longer blood glucose history which showed the resident's blood glucose had previously been stable with insulin/insulin pump coverage. The APRN said the physician gave orders to check finger sticks twice daily and they both expected nurses had performed the tests. On 7/31/25 at 10:02 AM, APRN D recalled on 5/14/25, two days after resident #1 was admitted to the facility, she let the physician know more medical records were needed. She said a blood test indicated the resident had stable blood sugars with the previous insulin regimen. The APRN explained the same day during a joint assessment of the resident with the physician, it was determined finger sticks were needed twice daily to see how often she would need insulin coverage. APRN D did not say why she never followed up on the blood glucose finger stick monitoring results or need for insulin. The APRN said the facility never had a resident with an insulin pump before and stated, she's on dialysis and that further complicates her condition. Review of resident #1's Order Audit Report showed the primary care physician entered orders on 5/15/25 at 2:47 PM for blood glucose finger stick monitoring every morning for five days for diabetes. The report noted Licensed Practical Nurse (LPN) C confirmed the order on 5/15/25 at 3:23 PM, three days after resident #1's admission to the facility. On 7/29/25 at 2:48 PM, LPN C explained it was the facility's practice to implement finger sticks for newly admitted residents who had been on insulin. The nurse explained when physicians entered their own orders into the computer, nurses verified the entry and confirmed it. The LPN recalled after the physician entered resident #1's Accu-Chek orders on 5/15/25, she confirmed it however, she later learned from the DON that it wasn't categorized properly. The nurse explained the order didn't go into the MAR to alert nurses to perform the test, and therefore the order was never implemented. APRN D's Follow Up Progress Note dated 5/15/25 documented time spent on resident #1's assessment took at least 55 minutes. No new glucose laboratory results were mentioned, and the section for Diabetes Mellitus diagnosis noted, no medications, and blood glucose trends revealed levels were stable and within normal limits, which was in conflict with the only result for blood glucose testing performed on 5/13/25 and resulted on 5/14/25 was 244 mg/dL. The note read, Hospital and facility records including but not limited to laboratory findings, radiology, clinical record, medication review, medication administration record reviewed in detail. Normal or target blood sugar levels for diabetes are less than 100 mg/dL for fasting blood sugar, 70-130 mg/dL before a meal, and less than 180 mg/dL after a meal. If you have unstable diabetes you may need to check your blood sugar multiple times a day, (retrieved on 8/14/25 from www.medicinenet.com). APRN D's Follow Up Progress Note dated 5/19/25 and signed at 11:43 AM, noted resident #1's assessment took at least 55 minutes. No new laboratory results were mentioned and there was no diagnosis of Diabetes Mellitus included under the Assessment/Plan. The note mentioned the hospital and facility records were reviewed in detail. The note contained an addendum dated 5/20/25 that documented staff had called to report resident #1 was found to be unresponsive and non-verbal with her right hand shaking or seizing; blood glucose level was obtained and read high. It was noted the resident was sent out to the emergency room (ER) for evaluation due to altered mental state and elevated blood glucose. The note indicated at 5:00 PM the resident was re-admitted to the hospital ICU with DKA (undated). In an interview on 7/31/25 at 2:48 PM, LPN B recalled on 5/19/25, resident #1 was part of her assignment. The nurse explained she observed the resident on the floor in her room beside the bed in an altered mental state with weakness, drowsiness, but no apparent injuries. The LPN said she notified APRN F who directed her to check the resident's blood sugar. She immediately attempted two finger sticks that both read, high, which was reported to APRN F who gave orders to send the resident out via 911 to the hospital. The nurse said she was unaware the resident was diabetic with an insulin pump until she called resident #1's mother about the change in condition. She said the resident's mother asked about finger stick results and was concerned about possible DKA. The Change In Condition (SBAR) [Situation Background Assessment Recommendation] notes completed by LPN B on 5/12/25 at 1:45 PM, revealed resident #1 was observed with increased confusion/disorientation, lethargy (fatigue/drowsiness), and a blood sugar machine reading of high. The SBAR noted at 12:30 PM, the physician was notified and gave orders to send the resident to the ER via 911 Emergency Medical Services. In a joint interview with the DON and ADON on 8/01/25 at 10:40 AM, the DON reviewed resident #1's 5/19/25 fall incident record. The DON explained that LPN B entered the resident's room at 12:20 PM and observed her sitting on the floor to the side of the bed. They said LPN B assessed the resident with no injuries and found a high blood glucose reading. They explained APRN D had seen the resident earlier that morning and was contacted by phone of the event. The DON stated, they got an order to send her out because of the high reading. The EMS Patient Care Record dated 5/19/25 noted an Emergency Dispatch (EMD) Complaint for, Diabetic Problem and a primary clinical impression of Diabetic Hyperglycemia for resident #1. The ED triage note dated 5/19/25 at 2:01 PM, indicated resident #1 arrived from the facility with a chief complaint of hyperglycemia (high blood glucose). The treatment initiated prior to arrival was a blood glucose check with a result of 582 mg/dL. The Primary Assessment section of the triage indicated resident #1 was awake, alert, and oriented to person, place and time. The ED RN documented, arrived via EMS for hyperglycemia. She wrote that EMS reported resident #1's blood glucose was 582 mg/dL, and upon arrival to ED fingerstick blood glucose was 560 mg/dL. The ED nurse documented resident #1 denied pain and was alert and oriented to person, place, time and situation, but said she felt weak. The hospital physician's admission notes dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated. The hospital primary care physician's notes indicated during emergency and ICU care, resident #1's blood glucose levels were, in the 600's. The Order Reconciliation Home Medications on hospital records dated 5/19/25 and the hospital Discharge Progress Notes Medication Update dated 5/23/25 for facility re-admission included Lispro Insulin 2 IU three times a day before meals, and Lantus Insulin 4 IU once a day. The Weights and Vitals Summary report showed resident #1 didn't receive any finger stick glucose checks from 5/12/25 to 5/19/25, for eight days. Over eight days from 5/12/25 until 5/19/25, while resident #1 did not receive the needed care and services for her type 1 diabetes, there were nine licensed nurses over three shifts, two APRNs, and one physician who evaluated, assessed, and made critical clinical decisions about resident #1's plan of care. In a telephone interview on 7/17/25 at 4:39 PM, resident #1's stepmother explained the facility had not properly monitored resident #1's diabetes which caused her to be re-hospitalized . She said since the incident, the resident's condition had declined, she required further therapy at an inpatient rehabilitation facility and stated, she's not doing very well. In a telephone interview from the inpatient rehabilitation facility on 8/02/25 at 10:08 AM, resident #1 explained she used the insulin pump at home before she was hospitalized in early May 2025. She said before her hospitalization, her mother assisted her with managing the insulin pump and to obtain prescriptions. Resident #1 had a broken speech pattern with delayed thought processing which caused frequent pauses. The resident said she never told any of the nurses or providers that she didn't use insulin. She relayed she had hoped to return home from the nursing home with her mother but needed additional therapy at an inpatient rehabilitation hospital to get better. She said she was weaker after her re-hospitalization on 5/19/25 and believed her condition had worsened since then. Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present at the meeting and expressed concerns to the facility regarding medication administration during her daughter's first admission to the facility from the hospital on 5/12/25. On 7/30/25 and 7/31/25, two unsuccessful attempts were made by telephone to interview resident #1's mother. On 7/29/25 at 11:20 AM, a telephone interview was conducted with resident #1's primary care physician. The doctor explained in May 2025, she was also the Medical Director of the facility and stated, I remember this case very specifically; I even texted the APRN, and I saw they didn't follow my orders for finger sticks; I was very upset. She recalled when she assessed resident #1 on 5/14/25, there were no insulin orders in the resident's EMR. The physician said she did not have all the hospital information when she assessed the resident and had she known about the insulin orders/pump, the plan of care would have been much different and included closer monitoring and more testing. The doctor said insulin pumps were dangerous, especially for someone on dialysis and could not be used in a Skilled Nursing Facility (SNF). The physician stated, She should have been monitored, it was a week [without insulin], and it could have been prevented; definitely she could have died. On 8/01/25 at 12:08 PM, the current Medical Director was interviewed. The physician said he had recently started in the role since mid-July 2025. He explained it was critical for nurses to inform doctors of an insulin pump, and he always expected finger stick orders to monitor blood glucose for diabetics with insulin, especially brittle ones. He said he assessed resident #1 after she returned from the hospital and her dialysis dependence made it even more crucial to monitor her diabetes condition closely. The physician explained that DKA was a serious complication and relayed the re-hospitalization could have been prevented if the resident was monitored during the seven days prior to the event, so that irregular or concerning highs and lows in blood glucose would have been caught. Review of resident #1's hospital admission records dated 5/19/25 confirmed the resident's admitting diagnosis was for Diabetes Mellitus with Ketoacidosis with blood glucose readings of greater than 600 ml/dL that required IV insulin, and ICU admission. Review of the ED treatments flowsheet dated 5/19/25 at 3:40 PM, revealed a foley urinary catheter was ordered and inserted by the nurse for urine output monitoring in the critically ill patient and to manage acute urinary retention. Review of her hospital Discharge Summary for her admission from 5/19/25 to 5/23/25 revealed the reason for hospitalization was DKA and the principal discharge diagnosis was DKA, resolved. The secondary diagnosis on discharge was candiduria, urinary tract infection. The HPI section documented by the hospital physician on 5/24/25 included this was a [AGE] year old female who presented to the emergency department from the [name of the SNF] with reported hyperglycemia. Past medical history included type 1 diabetes mellitus and end stage renal disease with dialysis. In the Discharge Summary the physician documented resident #1's blood sugar was in the 600's mg/dL, and her CO2 (Carbon Dioxide) was 16. The Hospital Course section detailed resident #1 was admitted to the hospital ICU due to DKA, given intravenous fluids and intravenous insulin drip. The physician described a urinalysis which was concerning for a UTI, so she was initially placed on an antibiotic, but after urine culture showed the infection was actually Candida she was switched to an antifungal medication. Normal carbon dioxide levels in the blood range from 20 to 29 millimoles/liter. Low CO2 levels can be a signal of health problems such as too much acid in the blood or ketoacidosis (DKA), (retrieved on 8/14/25 from myclevelandclinic.org). Candida fungal species are considered important parts of microbial normal flora in the mouth, ear and vagina in healthy people, and candida is normally colonized on the external side of the urethral opening in healthy females. This normally occurring yeast may turn opportunistic causing UTI due to predisposing factors in some people such as women, diabetics, having indwelling catheters, and malnutrition, (retrieved on 8/14/25 from nlm.nih.gov). Review of an undated statement completed by the facility's MD Consultant and presented during the survey by the facility, revealed in the MD statement, [resident #1's name] is a [AGE] year-old female with a complex medical history, including type 1 diabetes complicated by diabetic ketoacidosis. In conflict with the hospital physician's discharge summary, the consultant physician wrote that resident #1's primary reason for her admission was a Urinary Tract Infection (UTI), which is a well-documented cause of acute mental status changes. The consulting physician felt this was also the case with resident #1. The statement indicated the absence of any abnormal blood glucose levels during her hospitalization, made it .clear that there were no indications of acut

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement and review physician's admission orders for 1 of 3 residents reviewed for admission orders, of a total sample of 5 residents, (#1). The facility did not verify, implement, or initiate expected treatments and prescribed medications consistent with the resident's medical status and as listed in the hospital discharge summary. The Interdisciplinary Team (IDT) failed to recognize that essential components of the admission orders to maintain a chronic condition, including critical medications were missing or not transcribed into the Electronic Medical Record (EMR). This failure resulted in a lack of proper blood glucose monitoring and insulin medication for eight days, during which the resident developed Diabetic Ketoacidosis (DKA), a life-threatening condition. The resident required emergency 911 transfer to the hospital and re-hospitalization with Intensive Care Unit (ICU) level care, for five days. DKA is a life-threatening complication that affects people with diabetes and requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates an emergency medical situation. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin. Without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Most pumps are small, computerized devices that are roughly the size of a juice box or a deck of cards. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25). While hospitalized for five days, resident #1 required emergency Intravenous (IV) insulin and re-hospitalization with ICU care. She returned to the facility on 5/23/25 for continued recovery and therapy until 6/18/25, when the resident had a planned discharged to an inpatient rehabilitation hospital. On 5/12/25, the facility's nurses did not coordinate vital care needs with the on-call provider to ensure finger stick blood glucose monitoring and insulin orders were implemented on admission. On 5/13/25, the IDT reviewed resident #1's hospital records and admission orders but failed to recognize finger sticks and insulin orders were missing for a high-risk resident with an insulin pump. The resident's primary care providers did not recognize test results were missing that if implemented, would have detected resident #1's unstable blood glucose levels and prevented complications, worsening of condition, and mitigated the risk of serious injury/impairment/death. Eight days after resident #1 arrived at the facility, Monday, 5/19/25, a nurse observed her sitting on the floor in her room. After performing two finger stick blood glucose tests with readings of high (exceeded device measurement parameters), physician's orders were obtained to transport the resident to the hospital via 911 Emergency Medical Services (EMS) for dangerously high blood sugar. The facility's failure to recognize and implement proper provision of care and services with admission physician's orders for immediate care for a high-risk resident with type I Diabetes Mellitus and an insulin pump contributed to the destabilization of resident #1's medical conditions and placed newly admitted diabetic residents at risk for serious injury/impairment/death. For eight days, the facility was unaware resident #1 was missing critical medications and clinical monitoring until the resident's condition worsened with weakness, altered mental status and a subsequent fall. This failure resulted in Immediate Jeopardy which began on 5/12/25.Findings:Review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility from an acute care hospital on 5/12/25 with diagnoses that included: acute metabolic encephalopathy (brain dysfunction), diabetes mellitus, hyperglycemia (high blood sugar), other seizures, pneumonia, hypotension (low blood pressure), dependence on renal (kidney) dialysis, and history of blood clot. The Minimum Data Set 5-day Assessment with an Assessment Reference Date of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. She was noted with an altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered. The assessment indicated the resident received hemodialysis before admission and during the stay. Brittle diabetes is a healthcare term used to describe diabetes that's difficult to manage because of severe swings in blood sugar levels that can cause hospitalization. Swings can cause low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) which mainly affects people with type 1 diabetes, often due to other physician or mental health conditions. Symptoms of low blood sugar include weakness, confusion, clumsiness and seizures. Symptoms/complications of hyperglycemia include fatigue, increased infections including yeast infections, confusion, nausea and vomiting, (retrieved on 8/14/25 from www.myclevelandclinic.org). Resident #1's pre-admission clinical documents faxed from the hospital Case Manager on 5/08/25 for the facility's pre-admission review and acceptance noted the resident was admitted to the hospital on [DATE] for multiple episodes of loss of consciousness, and possible seizure. The History of Present Illness section of the physician's notes indicated the resident's family reported that no recent doses of medications were missed. The physician notes detailed that hyperglycemia (high blood sugar) was treated with sliding scale Insulin and Accu-Cheks (finger sticks). Resident #1's home medications were listed as Omnipod 5 Dexg7g6 Pods (Gen5) 1 dose daily via insulin pump, Lantus Insulin 4 Units (IU) subcutaneous (SQ) daily, and Lispro Insulin 2 IU SQ three times daily before meals. Review of the admission Packet sent with resident #1 from the hospital on 5/12/25 for facility admission revealed hospital physicians ordered discharge medications that included new medications and to continue taking other medications that were previously ordered including Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen5), 1 cartridge, 1 dose SQ daily, Lantus Insulin 4 IU SQ daily, and Lispro Insulin 2 IU SQ three times daily before meals. Lantus is a prescription drug used to help manage blood sugar levels in adults with type 1 and type 2 diabetes. It is a long acting insulin that is injected under your skin to add to or replace your body's natural insulin. Insulin Lispro is a prescription drug for managing blood sugar that is taken as an injection under your skin, intravenously or by insulin pump. This medicine acts quickly to lower your blood sugar, (retrieved on 8/14/25 from www.healthline.com). The Agency for Healthcare Administration (AHCA) Hospital Transfer Form 5000-3008 signed by the hospital provider dated 5/12/25, documented resident #1's Discharge Summary and Discharge Medication List reports were attached. The hospital discharge physician's ordered medication list dated 5/12/25 documented continued home medications included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose subcutaneous (SQ) daily, Insulin Glargine (Lantus), 4 units SQ daily, and Insulin Lispro, 2 units SQ three times daily before meals. Review of the May 2025 Medication Administration Report (MAR) showed physician's ordered admission medications on 5/12/25 included: Bumetanide (diuretic) 2 Milligrams (MG) once daily for pneumonia, Gabapentin (anti-convulsant) 300 MG at bedtime for diabetic neuropathy, Levothyroxine 50 Micrograms (MCG) once daily for hypothyroidism, Keppra 1000 MG twice daily for seizures, Lacosamide 100 MG twice daily for seizures, Creon (pancreatic enzymes) 12000-38000 IU three times daily for dialysis dependence, Midodrine 10 MG three times daily for low blood pressure, Oxycodone 10 MG every 6 hours as needed for pain. There were no orders for insulin or blood glucose monitoring noted on the MAR for May 2025. Review of resident #1's admission physician's orders dated 5/12/25 revealed the orders included all of the medications listed on the hospital physician's discharge medication orders, except for the insulin orders. No point of care blood glucose testing (finger sticks) was ordered. On 5/13/25 a care plan was initiated for Diabetes Mellitus with a goal for no complications, included interventions for diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms. Additional care plans dated 5/13/25 for risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, hypotension, neuropathy, fall risk score, and fall history; and for pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis, altered respiratory status. On 5/16/25 a care plan was initiated for adverse effects of high-risk medication monitoring, and risk for pressure injuries. In a telephone interview with Registered Nurse (RN) F on 7/30/25 at 1:20 PM, the nurse explained the facility's practice for new admissions included a review of the hospital's history and physical and discharge medications. She said the documents were sometimes scanned ahead of time to the EMR and an envelope with copies came with the resident from the hospital. The nurse explained normal practice was to notify the on-call provider, provide a report of the resident's medical history, and review the hospital discharge medication orders. The RN recalled resident #1 had an insulin pump and said finger sticks should have been ordered by either herself or the on-coming nurse. She explained admission orders were obtained from Advanced Practice Registered Nurse (APRN) E who wanted the resident's long-acting insulin to be further evaluated for appropriate orders with the pump. The RN stated, they [diabetic residents] need finger stick blood sugar orders; I'm not sure if it was an oversight on my part or my co-worker. In a joint interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), on 7/28/25 at 12:18 PM, the DON explained in addition to the admitting nurse's review, all new admissions were also reviewed every morning by the IDT to ensure accuracy and make any needed revisions. They confirmed APRN D was present for this meeting. The DON recalled there was a discussion about resident #1's insulin pump and it was unclear if it was used. The DON stated, she (APRN) reviews the discharge orders and if there are any discrepancies she covers that. At 12:24 PM, APRN D joined the interview by telephone. APRN D recalled resident #1's admission on [DATE] and said she was at the IDT meeting on 5/13/25. She said she presumed twice daily finger stick orders were already in place, but she didn't confirm it in the EMR, nor did she recall if anyone else checked. A review of APRN D's Admit Visit progress note dated 5/13/25 and signed on 5/15/25 listed resident #1's medications but did not include any insulin. The APRN documented that the hospital records with laboratory results were reviewed with a blood sugar result of 240. The Diabetes Mellitus diagnosis had comments including, blood glucose trends were stable and within normal limits and no medications were taken. Finger stick monitoring was not mentioned in the report. The Physical Exam did not note an insulin pump on her body but mentioned at least 60 minutes was spent assessing the resident. The Nursing admission Evaluation Comprehensive Nursing Assessment completed by RN F on 5/13/25 included a Drug Regimen Review section with documentation that a review of all medications was performed, no significant medication issues were found, and the MD was notified on 5/12/25. No response from the provider was noted. The list of medication classes was marked positive for diabetic medication. A Diabetic Medication Care Plan was checked as positive with an intervention for diabetic medication as ordered by the doctor and to monitor/document for side effects and effectiveness. In a telephone interview on 7/30/25 at 9:15 AM, APRN E explained she was the on-call provider on weekends and Monday nights. The APRN said she followed the hospital physician's discharge medication orders for new admissions, and she did not ever give orders to hold routine insulin. She did not recall resident #1 specifically but stated, I would still give orders for [blood glucose finger sticks], especially if they had an insulin pump. The MD History & Physical progress note dated 5/14/25 with 50-94 minutes of assessment duration, contained documentation that resident #1's most recent comprehensive laboratory results were reviewed with a blood glucose serum level of 244. The Diabetes Mellitus with hyperglycemia diagnosis had comments written that no blood glucose finger sticks were available for review and physician's orders were placed for daily blood glucose finger sticks to evaluate insulin. The EMR showed RN F admitted resident #1 on 5/12/25 at 10:00 PM during the 3:00 PM to 11:00 PM shift and handed off care to RN A on 5/12/25 for the 11:00 PM to 7:00 AM shift, on 5/13/25. In a telephone interview on 7/30/25 at 11:31 AM, RN A explained nurses relied on the hospital discharge medication orders and normally continued whatever insulin regimen was listed and always included finger sticks. The nurse said the medication list was scanned ahead of time into the EMR and/or copies were in an envelope (admission Packet) that came from the hospital with the resident. She explained the admitting provider was informed when residents had been on insulin. The RN said she worked during the 11:00 PM to 7:00 AM shift but could not recall if she specifically had resident #1 on her assignment for the 5/12/25 to 5/13/25 shift. On 7/29/25 at 2:48 PM, Licensed Practical Nurse (LPN) C explained it was the facility's practice to implement finger sticks for newly admitted residents who had been on insulin. The nurse recalled she usually worked the 7:00 AM to 3:00 PM shift and resident #1 had previously been part of her assignment. She said she was unaware the resident was diabetic and confirmed she should have at least received finger sticks with admission orders if the hospital records showed she was on insulin. The nurse said all new admission paperwork included an Admissions Checklist form. In a telephone interview on 8/01/25 at 11:55 AM, LPN J said she usually worked the 3:00 PM to 11:00 PM shift and recalled resident #1 was assigned to her a few times during her admission to the facility. The nurse said the evening shift received most of the new admissions from the hospital. She explained nurses used the hospital discharge summary and medications list, contacted the on-call provider, and obtained admission orders. The nurse said it was common and accepted practice for physicians to approve whatever medications were listed in the discharge orders. The nurse explained it was expected practice to initiate blood glucose finger stick orders for all diabetics who had insulin orders. In an interview with LPN B on 7/28/25 at 2:41 PM, the nurse recalled that approximately mid-morning on 5/19/25, she contacted resident #1's mother because she had a change in condition. She said the resident's mother told her she was supposed to be receiving insulin with finger sticks to check her blood sugar. The nurse said she explained that nurses got orders from the physician for whatever medications were listed on the hospital discharge medication list. The LPN stated, I'm not sure why insulin wasn't put on the admission orders, the family said she was supposed to be on insulin. The Change in Condition (SBAR) [Situation Background Assessment Recommendation] notes completed by LPN B on 5/12/25 at 1:45 PM, revealed resident #1 was observed with increased confusion/disorientation, lethargy (fatigue/drowsiness), and a blood sugar machine reading of high (unreadable over the machine's range). At 12:30 PM, the physician was notified and gave orders to send the resident to the emergency room (ER) via 911 EMS. Tight control of sugar in the blood with intensive insulin therapy reduces the risk of diabetic complications. Typical range for a point of care blood glucose machine is from 20 mg/dL to a high of 600 mg/dL, (retrieved on 8/15/25 from www.nlm.nih.gov). Review of the Weights and Vitals Summary report revealed no finger stick blood glucose checks were completed for resident #1 from 5/12/25 to 5/19/25, a total of eight days. In a joint interview with the DON and ADON on 7/28/25 at 12:18 PM, the DON explained hospital records were received both prior to admission and photocopies that contained the history and physical and physician's ordered discharge medications/treatments came later with the resident. She said it was the facility's practice, and her expectation that nurses reviewed the hospital medical history summaries and discharge medication list, contact the physician regarding the findings of the review, obtain admission orders, and enter/process them into the EMR. She recalled when resident #1 was admitted , the discharge medication list had handwritten marks by the insulin orders indicating for the APRN to review. A photocopy of the hospital's Follow-up and Plan - Discharge Orders Medications: Continue dated 5/12/25 that was scanned into resident #1's EMR showed handwritten stars marked beside the four insulin orders, as mentioned by the DON and ADON. The Emergency Medical Services Patient Care Record dated 5/19/25 indicated an Emergency Dispatch (EMD) Complaint for, Diabetic Problem and a primary clinical impression documented by the medics of Diabetic Hyperglycemia. The hospital physician's admission notes dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated. The hospital primary care physician's notes indicated during emergency and ICU care, resident #1's blood glucose levels were, in the 600's. In a telephone interview with resident #1's primary care physician on 7/29/25 at 11:20 AM, the doctor explained she expected hospital physician's discharge medication orders to be followed for new admissions and said blood glucose finger sticks were standard orders for all diabetics with insulin. She recalled when she saw resident #1 on 5/14/25 she did not know of any insulin orders and the EMR didn't have all the hospital records for her to review. She recalled the resident's blood glucose lab result was over 200 with a diagnosis of Diabetes Mellitus which needed to be evaluated for insulin. She said she was unaware until informed during the interview that the resident had an insulin pump and recalled resident #1's hospital records were later found after she assessed her on 5/14/25. In a telephone interview on 7/17/25 at 4:39 PM, and a written statement from 7/22/25 resident #1's stepmother explained the resident was an insulin dependent, brittle diabetic that had medication orders from the discharge hospital for insulin but did not receive them during her stay at the facility. Resident #1's stepmother indicated her daughter was unable to administer or ask for her medications herself due to her medical condition. She said while her daughter was at the facility they did not properly monitor her diabetes which caused her to be re-hospitalized . Resident #1's stepmother said she was found unresponsive by a nurse and sent to the hospital with DKA where she could have died. She said since the incident, the resident had declined and required further therapy at an inpatient rehabilitation facility and stated, she's not doing very well. On 7/30/25 and 7/31/25, two unsuccessful attempts were made by telephone to interview resident #1's mother. Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present for a care plan meeting and expressed concerns to the facility at that time regarding medication administration during her daughter's first admission to the facility from the hospital on 5/12/25. In an interview with the DON and NHA on 8/02/25 at 9:25 AM, the DON recalled on 6/13/25 during a care review meeting, it was identified that resident #1's finger stick orders entered on 5/15/25 were never implemented but she failed to explain why the admission insulin orders were missed. She explained an Ad Hoc meeting was held on 6/17/25 where a performance improvement plan (PIP) was developed for correction and monitoring to ensure accuracy of the EMR processing steps linked nurse prompts to the MAR, so tests would not be missed but they again failed to address why a newly admitted type 1 diabetic resident did not receive the hospital ordered insulin or why staff did not identify the resident's insulin pump and take action. The DON acknowledged resident #1's high blood sugar readings that were too high to register on the glucose monitor, but said they believed resident #1 was transferred to the ED because of the fall. The facility did not recognize the fall may have been an effect of the acutely high blood sugar readings. In a telephone interview from the inpatient rehabilitation facility on 8/02/25 at 10:08 AM, resident #1 explained she used the insulin pump at home before she was hospitalized in early May 2025. Resident #1 had a broken speech pattern and said she had delayed thought processing. This caused her to respond slowly to questions. Resident #1 stated she never told the facility about her insulin pump during the week before she was re-hospitalized , nor did she tell them she had not used her insulin pump recently. She could not recall if she or the facility staff ever spoke about finger stick blood glucose monitoring but explained before her initial hospitalization her mother assisted her to manage the device and obtain prescriptions. She relayed she had hoped to return home from the nursing home with her mother but now needed additional therapy at an inpatient rehabilitation hospital to get better. She said she felt weaker after her re-hospitalization on 5/19/25 and believed her conditions had worsened since then. On 7/29/25 at 11:20 AM, a telephone interview was conducted with resident #1's primary care physician. The physician said that in May 2025, she was also the Medical Director of the facility and stated, I remember this case very specifically; I even texted the APRN, and I saw they didn't follow my orders for finger sticks; I was very upset. She recalled when she assessed resident #1 on 5/14/25, there were no insulin orders in the resident's EMR. The physician said she did not have all of the hospital information when she assessed the resident and had she known about the insulin orders and pump, the plan of care would have been much different. She said the care would include closer monitoring of someone on dialysis and that an insulin pump could not be used in a Skilled Nursing Facility (SNF). The physician stated, She should have been monitored, it was a week, and it could have been prevented; definitely she could have died. On 8/01/25 at 12:08 PM, the current Medical Director was interviewed. The physician said he had recently started in the role mid-July 2025. He explained it was critical for nurses to inform physicians of a resident with an insulin pump, and he always expected finger stick orders to monitor blood glucose for diabetics with insulin, especially brittle ones. He said he assessed resident #1 after she was re-admitted from the hospital and her dialysis dependence made it even more crucial to monitor her diabetes condition closely. The physician explained that DKA was a serious complication and relayed the re-hospitalization could have been prevented if the resident was monitored during the prior seven days because irregular or concerning highs and lows would have been caught. Resident #1's unsigned Admissions Checklist form dated 5/12/25 noted 19 steps for nurses to follow that included: Verify medications with MD/NP (Medical Doctor/Nurse Practitioner), Complete the medication reconciliation, and put in medication orders. Review of the facility's standards and guidelines titled Nursing - Physician's Orders dated 3/10/23 noted nurses were responsible for monitoring orders including blood sugar. Review of the immediate actions implemented by the facility to remove the Immediate Jeopardy were verified by the survey team and included the following:*On 5/19/25, resident #1's physician was notified of a fall and change in condition with a blood sugar reading of high. The physician provided orders to send the resident to the hospital via 911 emergency for further evaluation. On 5/23/25, resident #1 returned to the facility from the hospital. Physician's admission Orders were implemented for Insulin and finger stick blood sugar monitoring.*From 6/13/25 to 6/17/25, nurse re-education was provided on the order entry EMR process, with specific focus on physician clarification, transcription and implementation of physician's orders. On 7/31/25, education was added for attention to orders related to the treatment of diabetes according to accepted standards of practice and facility standard practices. On 8/01/25, 82% of licensed nurses received the education that included retention verification with posttests. Any remaining nurses will be educated prior to working their next scheduled shift. Newly hired nurses will receive the education on Day 1 Orientation.*On 7/31/25, an audit was completed for 100% of current residents. Orders were verified as transcribed to reflect accurate eMAR (electronic medication administration record) and eTAR (electronic treatment administration record) documentation Identified concerns/discrepancies were corrected.*On 7/31/25, an audit was completed of all admitted /re-admitted residents in the previous 30 days. Physician's orders were verified to ensure appropriate orders consistent with accepted standards of practice and facility standard practices for the treatment of diabetes. No concerns were identified.*On 7/31/25, education for all licensed nurses was initiated for the following: 1. Hospital record review to include medication reconciliation, treatments, and order verification with the attending physician to ensure appropriate orders for the treatment of diabetes in accordance with accepted standards of practice and facility standard practices. 2. admission chart reviews during clinical meeting with two nurses to review all ordered medications and treatments. 3. Order Listing review for accuracy of all medications and treatments and their transcription to the eMAR. On 8/01/25, 82% of all licensed nurses had completed with posttests for retention validation. Remaining licensed staff were required to receive the education prior to working their next scheduled shift. Any newly hired staff will receive the education on day 1 orientation.*On 7/31/25, an Ad hoc (for this purpose) Quality Assurance Performance Improvement (QAPI) meeting was conducted that included Medical Director review of the F635 Immediate Jeopardy (IJ) template and the facility's immediacy removal plan of action. Upon review, the Medical Director approved the facility's proposed plan. Review of the in-service attendance sheets noted staff participated in education on the topics listed above.From 8/01/24 to 8/02/24, interviews were conducted with 11 licensed nurses who represented all shifts. 5 RNs and 6 LPNs verbalized their understanding of the education provided.The resident sample was expanded to include 4 additional residents identified with Diabetes Mellitus. Observations, interviews, and record reviews revealed no concerns related to admission orders or Diabetes for residents #2, #3, #4, and #5.Effective 8/01/25, the scope and severity were reduced to a level D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to obtain and implement critical physician medication admission orders for the care of a resident admitted from the hospital with a diagnosis of Type 1 Diabetes Mellitus for 1 of 3 residents, reviewed for admission orders, of a total sample of 5 residents, (#1).For eight consecutive days following admission, for all three nursing shifts and involving nine different licensed nurses, the facility did not obtain or implement physician orders for routine blood glucose monitoring (finger sticks) or insulin administration. This failure resulted in resident #1 developing severe hyperglycemia (high blood sugar) and Diabetic Ketoacidosis (DKA) requiring emergency transfer to the hospital, admission to the Intensive Care Unit (ICU), and emergency intravenous insulin therapy.DKA is a life-threatening complication that affects people with diabetes and requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates an emergency medical situation. People with type 1 diabetes can develop DKA at any point if they don't get enough insulin. Without treatment, DKA is fatal. Causes of DKA include missing a dose or more of insulin shots, or a clogged or empty insulin pump. DKA is diagnosed if your blood glucose level is above 250 milligrams/deciliter (mg/dL), your blood is acidic, you have ketone (acid molecules) in your urine or blood, and your blood bicarbonate level is lower than 18 milliequivalents/ liter. An insulin pump is a wearable medical device that supplies a continuous flow of rapid-acting insulin underneath your skin. Most pumps are small, computerized devices that are roughly the size of a juice box or a deck of cards. Finger stick tests are primarily used to monitor blood glucose levels, which is crucial for managing diabetes. Regular monitoring can prevent complications associated with high or low blood sugar, (retrieved from my.clevelandclinic.org on 8/08/25).This failure placed the resident in a situation in which serious injury/harm/impairment/death was likely to occur and resulted in the resident's hospitalization with life-threatening DKA requiring ICU-level care.Findings:Review of the medical record revealed resident #1, a [AGE] year old female was admitted to the facility from an acute care hospital on 5/12/25 with diagnoses that included acute metabolic encephalopathy (brain dysfunction), diabetes mellitus, hyperglycemia (high blood sugar), other seizures, pneumonia, hypotension (low blood pressure), dependence on renal (kidney) dialysis, history of blood clot, and hypothyroidism (low thyroid function).The Minimum Data Set 5-day Assessment with an Assessment Reference Date of 5/19/25 showed during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated she was cognitively intact. She was noted with altered level of consciousness that fluctuated and changed in severity. No behaviors or rejections of evaluation or care were noted. The assessment showed no insulin injections were administered. The resident received high-risk opioid and anticonvulsant medications. The assessment indicated the resident received hemodialysis before admission and during her stay.Review of the admission Packet sent with resident #1 from the hospital on 5/12/25 for facility admission revealed physician ordered discharge medications included, New: Oxycodone IR 10 Milligrams (MG) every 4 hours as needed for 3 days, Tylenol 650 MG every 6 hours as needed, Minoxidil 60 Gram Foam, topical (on skin) daily. Medications to continue included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen5), 1 cartridge, 1 dose SQ (subcutaneous) daily, Lantus Insulin 4 IU (International Units) SQ daily, and Lispro Insulin 2 IU SQ three times daily before meals, Creon 36,000 IU three times daily, Divalproex Sodium 500 MG twice daily, Lacosamide 100 MG twice daily, Levothyroxine 50 Micrograms (MCG) once daily, Midodrine 10 MG three times daily, Gabapentin 300 MG at bedtime.Review of the May 2025 Medication Administration Report (MAR) showed resident #1's 5/12/25 admission physician orders included, Bumetanide (diuretic) 2 MG once daily for pneumonia, Gabapentin (anti-convulsant) 300 MG at bedtime for diabetic neuropathy, Levothyroxine 50 Micrograms (MCG) once daily for hypothyroidism, Keppra 1000 MG twice daily for seizures, Lacosamide 100 MG twice daily for seizures, Creon (pancreatic enzymes) 12000-38000 international units (IU) three times daily for dialysis dependence, Midodrine 10 MG three times daily for low blood pressure, Oxycodone 10 MG every 6 hours as needed for pain. There were no orders for insulin or blood glucose monitoring noted on the MAR for May 2025.After the resident returned from the hospital on 5/23/25, orders were added that included Lantus Insulin 4 IU once daily for diabetes mellitus increased to 6 IU on 5/31/25, Lispro Insulin 2 IU before meals and changed on 5/24/25 to Novolog Aspart Insulin 2 IU before meals with finger sticks and parameters to notify the APRN (Advance Practice Registered Nurse) for readings of less than 60, or more than 250 for diabetes mellitus, and Accu-Chek (blood glucose monitoring finger sticks) twice daily with parameters to notify the MD (Medical Doctor) when less than 60, or more than 400.The Agency for Healthcare Administration (AHCA) Form 5000-3008 signed by the hospital provider dated 5/12/25 documented resident #1's Discharge Summary and Discharge Medication List reports were attached.The hospital discharge physician ordered medication list dated 5/12/25 documented continued home medications included: Insulin Pump Omnipod 5 Dexg7g6 Pods (Gen 5) cartridge, 1 dose SQ daily, Insulin Glargine (Lantus), 4 IU SQ daily, and Insulin Lispro, 2 IU SQ three times daily before meals.Resident #1's physician's facility admission orders for 5/12/25 included all medications listed on the hospital physician's discharge medication orders, except for insulin. No finger sticks were ordered.Resident #1's Care Plan Report showed a care plan was initiated on 5/13/25 and revised on 6/03/25 for Activities of Daily Living (ADLs) self-care performance deficit related to Diabetes type I, history of recent DKA, encephalopathy, history of acute kidney injury, dependence on dialysis, chronic hypotension, neuropathy, hypothyroidism, and asthma. Interventions included for nurses to monitor/document/report any changes or declines in function. Other care plans included: (5/13/25) Diabetes Mellitus with a goal for no complications and interventions for Diabetes medication as ordered by doctor, medication education with verbal understanding, labs, food/nutrition substitutions, and nurse monitoring for abnormal blood glucose signs/symptoms, (5/13/25) risk for falls related to weakness, limited mobility, seizure history, hypoglycemic use, hypotension, neuropathy, fall risk score, and fall history, (5/13/25), pain and pain medication, right chest dialysis catheter monitoring, nutritional problems related to diabetes, kidney disease, and dialysis, altered respiratory status, (5/16/25) adverse effects of high-risk medication monitoring, risk for pressure injuries, (5/27/25) seizure history, and indwelling urinary catheter with failed voiding trial, dehydration or potential fluid deficit related to diuretic medication, hemodialysis, type I diabetes with recent DKA, and (6/02/25) hypoglycemia. The discharge care plan initiated on 5/13/25 noted the resident wished to be discharged from the facility to community/prior living arrangements (home).In a telephone interview on 7/30/25 at 1:20 PM, Registered Nurse (RN) F explained the process for new admission included a review of the hospital's history and physical and discharge medications. She stated the normal practice was to notify the on-call physician, provide a report of the resident's medical history, and review the hospital discharge medication orders. The RN recalled resident #1 had an insulin pump and relayed that finger sticks should have been entered by either herself or the on-coming nurse. She explained admission orders were obtained from APRN E who wanted the resident's long-acting insulin further evaluated for appropriate orders with the pump. The RN stated, they need finger stick blood sugar orders, I'm not sure if it was an oversight on my part or my co-worker.On 7/29/25 at 10:46 AM, APRN D recalled she participated in the Interdisciplinary team (IDT) meeting on 5/13/25, the morning after resident #1 was admitted . She explained APRN E gave admission orders to hold the insulin. She said the resident's hospital records were reviewed which noted the resident had type 1 Diabetes, and it was common knowledge to do finger stick checks for all diabetics with insulin, especially those who were very brittle with an insulin pump. She said pumps could not be managed in a Skilled Nursing Facility (SNF). The APRN said she assumed there were already orders in place for finger sticks twice a day and she did not recall if the records were checked during the meeting for confirmation.Brittle diabetes is a healthcare term used to describe diabetes that's difficult to manage because of severe swings in blood sugar levels that can cause hospitalization. Swings can cause low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) which mainly affects people with type 1 diabetes, often due to other physician or mental health conditions. Symptoms of low blood sugar include weakness, confusion, clumsiness and seizures. Symptoms/complications of hyperglycemia include fatigue, increased infections including yeast infections, confusion, nausea and vomiting, (retrieved on 8/14/25 from www.myclevelandclinic.org).In a telephone interview on 7/30/25 at 9:15 AM, APRN E explained she was the on-call provider on weekends and Monday nights. The APRN said she followed the hospital physician's discharge medication orders for new admissions, and she never gave orders to hold new admission routine insulin. She did not recall resident #1 specifically and stated, I would still give orders for finger stick blood glucose monitoring, especially if they had an insulin pump.Review of APRN D's Admit Visit progress note dated 5/13/25 and signed on 5/15/25 listed resident #1's hospital discharge medications but did not include any insulin. The hospital records with laboratory results were noted as reviewed with a blood sugar result of 240. The Diabetes Mellitus diagnosis had comments noted as, blood glucose trends were stable and within normal limits and no medications were taken. Blood glucose finger stick monitoring or review was not mentioned in the report. The Physical Exam did not note an insulin pump on resident #1's body but the note mentioned at least 60 minutes was spent assessing the resident.The physician's History & Physical progress note dated 5/14/25 with 50-94 minutes of assessment duration documented resident #1's most recent comprehensive laboratory results were reviewed with a blood glucose serum level of 244. The Diabetes Mellitus with hyperglycemia diagnosis had comments that noted no blood glucose finger stick results were available for review, so physician orders were placed for daily blood glucose finger sticks to evaluate the need for insulin.In a telephone interview with resident #1's primary care physician on 7/29/25 at 11:20 AM, the doctor explained she expected hospital physician discharge orders to be followed for medications, and blood glucose finger sticks were standard orders expected for all diabetic residents with insulin. She explained when she saw resident #1 on 5/14/25 she did not recall any insulin orders. She did recall the resident's blood glucose was over 200 with a diagnosis of Diabetes Mellitus which needed to be evaluated for insulin coverage. The doctor stated she sent a text message the same day to APRN D with directives to follow up. She said she was unaware until the surveyor's telephone interview that the resident had an insulin pump.In interviews on 7/29/25 at 10:46 AM, and 7/31/25 at 10:02 AM, APRN D recalled on 5/14/25, she jointly assessed resident #1 with the MD. She said on 5/13/25, she ordered labs to check a longer blood glucose history that showed the resident's blood glucose was stable with insulin/insulin pump coverage. The APRN said the MD gave orders to check finger sticks twice daily and they both expected nurses had done them. APRN D recalled on 5/14/25, two days after resident #1 was admitted to the facility, she let the MD know more medical records were needed. She said a blood test showed the resident had stable blood sugars with the previous insulin regimen. The APRN explained the same day during a joint assessment of the resident with the physician, it was determined finger sticks were needed twice daily to see how often she would need insulin coverage and recalled the pump was on her torso, but she didn't see it or remember how it was hooked up. The APRN said the facility never had a resident with an insulin pump before and stated, she's on dialysis and that further complicates her condition. APRN D referred to resident #1 and stated, When her records were reviewed in the morning, we saw she was a type 1 (diabetic); usually there are standing orders; all diabetics should have finger sticks; it's common knowledge to do finger sticks for all diabetics; when she came back from the hospital (5/23/25), it was apparent she was unpredictable.Review of resident #1's Order Audit Report showed the primary care physician entered orders on 5/15/25 at 2:47 PM, for blood glucose finger stick monitoring daily for 5 days in the morning for diabetes. The report noted Licensed Practical Nurse (LPN) C confirmed the order on 5/15/25 at 3:23 PM.On 7/29/25 at 2:48 PM, LPN C explained that it was the facility's practice to place newly admitted residents who had been on insulin with finger stick blood glucose monitoring orders. The nurse explained when doctors entered their own orders into the computer, nurses verified the entry and confirmed it. The LPN recalled after the physician entered resident #1's finger stick blood glucose monitoring orders on 5/15/25, she confirmed it however, she later learned from the Director of Nursing (DON) that it wasn't categorized properly, so it didn't get entered into the MAR to alert nurses to perform the test. The nurse said she was not aware resident #1 had an insulin pump and stated, we don't do insulin pumps.In a telephone interview on 7/30/25 at 11:31 AM, RN A said she worked the 11:00 PM to 7:00 AM shift. She said hospital admissions usually arrived during the 3:00 PM to 11:00 PM shift and most of the time, physician admission orders were already entered and processed during that shift before she came in. The nurse explained she did not recall if on 5/13/25 the previous shift's nurse informed her that resident #1 needed insulin or finger stick orders clarified. The nurse said she had never received report from other nurses of any resident at the facility with an insulin pump.In a telephone interview on 8/01/25 at 10:53 AM, RN I explained medication orders for residents admitted from the hospital were transcribed from the physician's discharge orders list. The nurse recalled resident #1 was included in her assignments when she worked all shifts. She said she never received information in nurse-nurse reports that the resident had an insulin pump. The RN explained licensed nurses were expected to use proper nursing judgement when they cared for insulin-dependent diabetic residents. She added, nurses were trained to contact the provider when they noticed finger stick or insulin orders were missing and stated, it's basic nursing.On 8/01/25 at 1:14 PM, in a telephone interview, RN H recalled resident #1 and was unsure if the resident had an insulin pump. The RN explained all nurses were expected to know residents who had been on insulin, especially with a pump, were likely unstable and required close blood glucose monitoring. The nurse said when skin assessments were done, any device on the resident's body was supposed to be noted on the assessment. She said it was important for nurses to pay attention to diabetics for insulin and finger stick orders and the physician needed to be informed to obtain orders if they were missing.In a telephone interview on 8/01/25 at 11:19 AM, LPN J recalled resident #1 was included in her assignments throughout her stay. She said nurses were expected to note any devices or ports with their locations on the skin assessments, and she didn't remember the resident having an insulin pump. The LPN explained nurses were expected to ensure finger stick orders were in place for any resident with insulin. The nurse stated, I would need to contact the provider for finger sticks.On 8/01/25 at 10:51 AM, LPN G recalled when resident #1 came to the facility the first time, she was on orientation and there was nothing significant about her condition. The nurse said she didn't remember seeing an insulin pump or any discussions/reports from other nurses and stated, I'm surprised nobody captured that; she was undressed many times.On 8/01/25 at 3:38 PM, LPN K said she worked the 3:00 PM to 11:00 PM shift. The nurse said she did not recall anything about an insulin pump for resident #1. She explained that anyone with an insulin pump should have finger sticks and stated it was concerning if she didn't see those orders. The LPN stated, I would question why there aren't finger sticks; it's nursing 101.On 7/28/25 at 2:41 PM, LPN B said she worked the 7:00 AM to 3:00 PM, shift and resident #1 was included in her assignments. The nurse recalled around mid-morning on 5/19/25, she was alerted by a Certified Nursing Assistant (CNA) that something was wrong with the resident. The LPN said she called the resident's mother about a change in condition and was informed the resident was insulin-dependent and at risk for DKA. The nurse explained she had not received that information in nurse-nurse report from the out-going shift and wasn't sure why the resident wasn't on insulin. She performed two finger sticks that both read high which meant it was too high for the glucometer to read. After the LPN contacted APRN D to inform her of the readings, the APRN gave orders to send the resident via 911 emergency transportation to the hospital.Review of resident #1's admission and weekly skin assessments throughout her stay from 5/12/25 to 5/19/25, revealed no documentation of insulin pump device present.The EMS (Emergency Medical Services) Patient Care Record dated 5/19/25 noted an Emergency Dispatch (EMD) Complaint for, Diabetic Problem and a primary clinical impression of Diabetic Hyperglycemia.Review of resident #1's hospital admission records dated 5/19/25 confirmed the resident's admitting diagnosis was for Diabetes Mellitus with Ketoacidosis (DKA) with blood glucose readings of greater than 600 milligrams per deciliter that required IV insulin, and ICU admission.The hospital physician admission note dated 5/19/25 read, The patient is critically ill requiring high-risk and invasive therapies, intensive monitoring, and complex medical decision-making to prevent otherwise inevitable life-threatening organ system decompensation if untreated.Review of the Care Conference Record dated 6/12/25 noted resident #1's mother was present and expressed concerns regarding medication administration during her daughter's first admission to the facility from the hospital on 5/12/25.On 7/28/25 at 12:40 PM, the DON said she became aware of resident #1's missing finger sticks on 6/13/25 after a routine chart review. She explained the nurse had not properly confirmed the order in the EMR after it was entered by the MD on 5/15/25. The DON said the error prevented prompts from appearing on the nurse's MAR which directed the nurses to perform the tests, so they were not done. On 7/30/25 at 11:01 AM, in a joint interview with the DON and Assistant DON (ADON), the DON said the clinical team reviewed all hospital re-admissions including resident #1's on 5/19/25. The DON stated, we didn't connect the missed orders.Nursing progress notes from 5/12/25 to 5/18/25 contained no documentation history of blood glucose checks nor notations that resident #1 indicated to anyone she had not recently used her insulin pump at home.The admission Nursing assessment dated [DATE] identified diabetes as an active diagnosis but did not include physician orders for blood glucose monitoring or insulin administration.Interviews with eight licensed nurses confirmed awareness of the resident's diabetic status but no action to clarify or obtain orders for glucose monitoring or insulin administration.On 7/29/25 at 11:20 AM, a telephone interview was conducted with resident #1's primary care physician. The doctor said in May 2025, she was also the Medical Director of the facility and stated, I remember this case very specifically; I even texted the APRN, and I saw they didn't follow my orders for finger sticks; I was very upset. She recalled when she assessed resident #1 on 5/14/25, there were no insulin orders in the resident's EMR. The physician said she did not have all the hospital information when she assessed the resident and had she known about the insulin orders/pump, the plan of care would have been much different and included closer monitoring and more testing. The doctor said insulin pumps were dangerous, especially for someone on dialysis and could not be used in a Skilled Nursing Facility (SNF). The physician stated, She should have been monitored, it was a week, and it could have been prevented; definitely she could have died.On 8/01/25 at 12:08 PM, the current Medical Director was interviewed. The physician said he had recently started in the role since mid-July 2025. He explained it was critical for nurses to inform doctors of an insulin pump, and he always expected finger stick orders to monitor blood glucose for diabetics with insulin, especially brittle ones. He said he assessed resident #1 after she returned from the hospital and her dialysis dependence made it even more crucial to monitor her diabetes condition closely. The physician explained that DKA was a serious complication and relayed the re-hospitalization could have been prevented if the resident was monitored during the seven days prior to the event, and that irregular or concerning highs and lows would have been caught.Review of the EMR revealed after resident #1 returned to the facility from the hospital, from 5/23/25 through 6/18/25, she required routine and sliding scale insulin coverage with finger stick checks twice daily, and before meals. Prescribed insulin doses were revised three times when her blood sugar levels were unstable until she was discharged on 6/18/25.In a joint interview with the DON and ADON on 8/01/25 at 10:40 AM, the ADON explained she was the facility's clinical educator and conducted nurse training for new hire orientation and re-education. The ADON said education was provided for nurses that covered the facility's policies and procedures and a competency checklist. She said competency was validated using observation, demonstration, and the checklist. The DON explained re-hospitalizations were reviewed during the IDT clinical meetings every weekday morning. The DON stated when the IDT reviewed resident #1's 5/19/25 re-hospitalization, they found the resident had high blood sugar.Review of the facility's nurse's orientation program on 8/02/25, included education for physician's order processing and accuracy review. Blood glucose monitoring via finger stick education noted that nurses were expected to contact the physician for needed follow-up/clarifications.The LPN job description dated May 2022 listed Duties and Responsibilities that included consultation and coordination with the IDT and health care professionals to assess, plan, implement, and evaluate individual resident care plans. Specific Requirements included the ability to plan and provide procedures necessary to provide quality care, the ability to communicate information concerning a resident's condition, and knowledge of nursing and practices and procedures.The RN Job Description dated May 2022 listed Duties and Responsibilities that included consultation and coordination with the IDT and health care professionals to assess, plan, implement, and evaluate individual resident care plans. Essential functions included monitoring the chronic health conditions of residents; being familiar with reportable changes and potential causes for concern. Specific Requirements included the ability to plan and provide procedures necessary to provide quality care, the ability to communicate information concerning a resident's condition, and knowledge of nursing and medical practices and procedures.The DON's Job Description dated October 2020 noted the primary purpose included to ensure that the highest degree of quality care was maintained at all times. Duties and Responsibilities included to ensure that competent and qualified individuals provided nursing care. Nursing care functions included monitoring of residents for preventable decline, and monitoring medication passes and treatment schedules to ensure medications and treatments were provided as scheduled.The undated Nurse Practitioner Job Description noted the APRN was the go-to person for ensuring the best patient care and medical guidance was achieved. Responsibilities included examining patients and their medical records, ordering and studying diagnostic tests, prescribing medications, maintaining accurate schedules and records, and proposing treatments for chronic conditions and illnesses.The Facility Assessment Tool dated 2/01/25 noted the facility provided services for medication administration/assessment/management, management/early identification of problems/deterioration of medical conditions including diabetes. Staff training/education and competencies were noted as verified upon orientation, at least annually, and as needed designed to ensure competency for all staff. Review of the immediate actions implemented by the facility to remove the Immediate Jeopardy were verified by the survey team and included the following:*On 5/19/25, resident #1's physician was notified of a fall and change in condition with a blood sugar reading of high. The physician provided orders to send the resident to the hospital via 911 emergency for further evaluation. On 5/23/25, resident #1 returned to the facility from the hospital. Physician's admission Orders were implemented for Insulin and finger stick blood sugar monitoring.*On 7/31/25, licensed nurse education on Diabetes Management was initiated that included recognition of residents with high-risk type 1 Diabetes Mellitus and blood sugar treatment and monitoring requirements to prevent severe complications. On 8/01/25, 71% of all licensed nurses received the education that included retention verification with posttests. Any remaining nurses will be educated prior to working their next scheduled shift. Newly hired nurses will receive the education on Day 1 Orientation.*On 7/31/25, 100% of current residents with diagnosis of diabetes were audited to ensure blood sugar monitoring was performed and documented per physician's orders.*On 7/31/25, licensed nurse education was initiated that included: 1. Diabetic management on type 1 diabetes and signs and symptoms of hypoglycemia and hyperglycemia and when to notify the physician. On 8/01/25, 71% of all licensed nurses received the education that included retention verification with posttests. Any remaining nurses will be educated prior to working their next scheduled shift. Newly hired nurses will receive the education on Day 1 Orientation.*On 7/31/25, an Ad hoc (for this purpose) Quality Assurance Performance Improvement (QAPI) meeting was conducted that included Medical Director review of the F726 Immediate Jeopardy (IJ) template and the facility's immediate removal plan of action. Upon review, the Medical Director approved the facility's proposed plan. Review of the in-service attendance sheets noted staff participated in education on the topics listed above.From 8/01/24 to 8/02/24, interviews were conducted with 11 licensed nurses who represented all shifts. 5 RNs and 6 LPNs verbalized their understanding of the education provided.The resident sample was expanded to include 4 additional residents identified with Diabetes Mellitus. Observations, interviews, and record reviews revealed no concerns related to admission orders or Diabetes for residents #2, #3, #4, and #5.