Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for the treatment of Type II Diabetes Mellitus for 3 (R3, R19, R20) of 4 residents reviewed for labs in the sample of 21. This failure resulted in abnormal lab values not being immediately communicated with the physician and R3 experiencing altered mental status requiring transport to the Emergency Department where a blood glucose level of 819 was found. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 2/8/23 when abnormal Hemoglobin A1c results for R3 were reported to the facility and staff did not complete the facility procedure of notifying the physician of these values until 3/20/23. V1 (Administrator) was notified of the Immediate Jeopardy on 10/4/23 at 1:10 PM. The surveyors confirmed by observations, interview, and record review that the Immediate Jeopardy was removed on 10/5/23 but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: 1. Review of R3's admission Record documented his initial admission date to the facility as 9/16/21. R3's Primary Physician is listed as V13 (Physician) and Power of Attorney for care is V5 (Family Member). R3's Cumulative Diagnosis Log includes but is not limited to the following diagnoses: coronary artery disease; Dementia; Chronic Kidney Disease, Stage 3; Peripheral Neuropathy; Hypertension; Diabetes Mellitus II, with the date identified listed as 12/8/22. Facility policy titled, (company) Notification for Change in Resident Condition or Status with an issue date of 7/1/12 documents, The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON (Director of Nursing), Physician, Guardian, HCPOA (Health Care Power of Attorney, etc.) of changes in the resident's medical/mental condition and/or status. The procedures stated, 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: .m. Abnormal lab findings .3. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status .5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Facility policy titled, (company) Laboratory Tests with a reviewed date of 9/27/17 documents the facility policy as, Appropriate laboratory monitoring of disease processes and medications requires consideration of many factors including concomitant disease(s) and medications(s), wishes of the resident and family and current standards of practice. A pharmacy consultation report dated 1/27/23 stated, (Name) R3 has diabetes and does not receive medications, but an A1c (Glycated Hemoglobin) is not available in the medical record in the past 6 months. Fasting blood sugar on 11/16/22 was 213. Recommended was, Please monitor A1c on the next convenient lab day. V13 (Physician) is documented on this form as accepting these recommendations, and labs will be drawn on 2/8/23 as well as an additional order given for an A1c to be drawn in July 2023. R3's lab results documented a specimen collection date of 2/8/23, with a H (high) Hemoglobin A1c result of 9.9. The normal reference range of 4.8 % - 5.6 % is listed on this same document. The lab documented R3's estimated average glucose level to be 237, correlating with these A1c results. This lab document noted a handwritten comment of faxed 2-8-23. These labs are documented as being faxed to the facility from the local hospital on 2/8/23 at 12:42 PM as evidenced by the fax server time stamp. R3's Physician Progress note made by V13 (Physician), dated 2/8/23 documented he was seeing R3 for a routine evaluation. V13 documented R3's blood sugar levels as being controlled, running about 150. V13 documented the last A1c level was on 11/16/22 with a value of 7.3. V13 gave no new orders regarding this evaluation and does not note lab results from 2/8/23. The first documented communication with V13 regarding the 2/8/23 A1c level is on 3/20/23. Review of R3's 3/20/23 Physician Progress note made by V13 documented R3 was a diabetic with his A1c being a little high at 9.9. V13 documented R3 is post-covid, and he will look at R3 when he is well. The Disposition listed on this same note documented R3 ordered a chest x-ray and labs, which included an A1c and complete metabolic panel (CMP). R3's lab results documented a specimen collection date of 3/22/23, with a H A1c level of 10.3. The normal reference range of 4.8% - 5.6% is listed on this same document. The lab documented R3's estimated average glucose level to be 249, correlating with these A1c results. This lab document noted a handwritten comment of faxed (V19 (Registered Nurse) initials). Additional lab results with a collection date of 3/22/23, document an actual glucose level of 259. The normal range listed for this lab value is (70-100). The A1c lab is documented as being faxed to the facility from the local hospital on 3/22/23 at 11:08 AM as evidenced by the fax server time stamp. The glucose lab is documented as being faxed to the facility on 3/22/23 at 8:01 AM as evidenced by the fax server time stamp. No definitive documented communication can be confirmed that V13 was ever notified of these results. R3's Physician Progress note made by V13 on 4/3/23 documents, We looked at the laboratory . although specific labs review is not noted. No new orders were documented on this progress note. R3's Skilled Progress Note dated 3/22/23 made by V19, documented communication with V13 regarding an abnormal chest x-ray result, but no mention of labs. Nurse's Notes dated 5/15/23 at 6:00 PM documented, Resident (R3) very confused and not himself. Was reported that he was unable to feed self and dumped 2 glasses of water r/t (related to) unable to grasp items. Resident incontinent at this time. Resident unable to form sentences and speaking garbled words. Vitals obtained and blood sugar. Blood sugar reading HI >600. (Name) V13 notified and send to hospital order given. (relationship/name) V5 notified. Ambulance service called. Report called and given to ER (Emergency Room) dept. (department). Awaiting ambulance at this time. The next Nurse's Note is dated 5/15/23 at 6:50 PM, Ambulance service here along with (name/relationship) V5. Resident put on transport cart without difficulty. Both (all) departed at 7:05 PM. Will follow up with ER dept. R3's document titled, ED (Emergency Department) Events dated 5/15/23 documented the first provider evaluation was done by V23 (APRN-CNP/Advanced Practice Registered Nurse - Certified Nurse Practitioner) at 7:18 PM. Chief complaint is listed as altered mental status. V23 documented, R3 presented to the ED with EMS (Emergency Medical Services). EMS reported upon their arrival they found R3 appearing sedated and confused with some slurred speech. V23 also documented, Last known normal is unclear, as staff at the nursing home report he has been progressively more confused over the past couple of days. R3's initial labs listed in this same document note R3's Glucose level as 819 HH (extremely high). The reference range listed for the glucose level is 70 - 100 mg/dL (milligrams per deciliter). The Clinical Impressions as of 5/16/23 at 1:44 AM are listed as: Altered Mental Status, unspecified altered mental status type; Type 2 Diabetes Mellitus with hyperglycemia, without long-term current use of insulin; Dehydration. The Plan documents an insulin drip was initiated, and glycemic control was achieved. V23 noted review of R3's clinical chart documented an A1c level of greater than 7 for the past year, most recently 10.3 on 3/22/23, with no initiation of diabetic medications. R3 is documented as being admitted to hospital for continued glycemic monitoring and initiation of diabetic medications prior to discharge back to the nursing home. R3 is documented as now being conversant and oriented to person, place, time, and situation once glycemic control was achieved. R3's Medicine Discharge Summary documented an admit date to the local hospital for R3 as 5/15/23 and discharge date of 5/20/23. R3's admission and Discharge Diagnosis include the diagnosis of Uncontrolled diabetes mellitus with hyperglycemia. The Hospital Course documents R3 was transported to the ED with a workup completed for a possible stroke, but no acute intercranial problems were discovered. R3's Glucose level was found to be 819, and includes the notation of, Looking back at the nursing home patient had hemoglobin A1c done 2 months ago was 10.3 which gives an average of 249. The patient was not started on medications. R3's A1c listed as being completed in the hospital on 5/16/23 at 5:17 AM document a A1c level of then 13.8. Discharge medications include the addition of subcutaneous use of insulin glargine and insulin lispro. R3's Progress Note dated 6/5/23 documented V13 (Physician) was examining R3 on this date due to a hospitalization when his blood sugar went to 800. The note goes on to say, Let me look at his sugars. We are going to go back and find out what his sugars are. We have a hemoglobin A1c too high. It is 10.3 and this was on 3/22 So, hemoglobin A1c is too high. Now, let's look at blood sugars. Now, we are going to the computer. I assume some electronic medical records. We are having trouble finding the sugars. They have totally thinned the charts getting ready for electronic medical record. They are not here. So, we are still searching. They are bound to be some place. The disposition listed in this note included new lab orders, one being an A1c. Lab results documented a specimen collection date of 6/14/23, with a H A1c level of 10.5. The normal reference range of 4.8% - 5.6% is listed on this same document. The lab documented R3's estimated average glucose level to be 255, correlating with these A1c results. This lab document noted a handwritten comment of faxed (V19 (Registered Nurse) initials). Additional lab results with a collection date of 3/22/23, document an actual glucose level of 130. The normal range listed for this lab value is (70-100). Review of R3's Clinical Record documented V13 was notified of the 6/14/23 lab results on 6/15/23, with medication order changes given. Lab results document a specimen collection date of 7/12/23, with a H A1c level of 7.9. The normal reference range of 4.8% - 5.6% is listed on this same document. The lab documented R3's estimated average glucose level to be 180, correlating with these A1c results. This lab document noted a handwritten comment of faxed. The A1c lab is documented as being faxed to the facility from the local hospital on 7/12/23 at 7:40 AM as evidenced by the fax server time stamp. The first documented communication with V13 regarding the 7/12/23 A1c level is on 8/7/23. V13 had no new orders at this time. On 10/3/23 at 9:54 AM, V13 stated he doesn't recall being notified of R3's 3/22/23 A1c level of 10.3 or glucose level of 259. V13 stated he cares for a lot of people though, so the facility should document their communication with him. V13 stated that those levels would have been results he would have had further orders for, at minimum, repeat orders. V13 was notified of his 4/3/23 progress note in which he stated he reviewed lab but does not specify which ones. V13 stated it can be suggested the 3/22/23 labs were not presented to him, given there were no new orders. V13 stated at any rate, he would expect to be notified of abnormal lab results immediately. V13 stated that uncontrolled blood sugar can lead to complications and even possible death, although he states it would have to be severe and may be a stretch. V13 confirms that a glucose level of 819 is critical and would require immediate intervention. V13 also stated he has no nurse practitioner who works with him and completes resident examinations himself. V13 stated that labs listed in the disposition section of his notes are orders he is giving. On 10/3/23 at 10:23 AM, V9 (Licensed Practical Nurse/LPN) stated the process for labs is that all labs are faxed to the physician, and if they are abnormal a call is made to notify the physician of the level. V9 stated if the labs are normal, they are placed in the resident's record after being faxed for the physician review the next time they are in the facility. V9 stated that V13 is easy to get a hold of and a good communicator with the facility. V9 stated that R3 was not having his glucose monitored except for via labs prior to his May 2023 hospitalization. On 10/3/23 at 10:59 AM, V2 (Director of Nursing) stated that the local hospital is the only entity the facility utilized for lab testing. V2 stated the process for labs in the facility is that once labs are ordered the labs are obtained as indicated. V2 stated the hospital will fax the results of the labs to the facility. V2 stated that a nurse on duty should then fax the lab results to the physician and call the physician if the lab results are abnormal. V2 stated that the labs are always faxed to the physician so that the physician can keep a copy in their record too. V2 stated that routine labs with normal values would be placed in the resident's record for the physician to review during the next time they make rounds in the facility. V2 stated that abnormal lab values that are phoned to physician would have that communication documented in the progress notes. V2 stated that she believes it was just an error on the nurse's part that communication with the physician regarding R3's abnormal glucose/A1c labs was not documented. V2 stated that V13 is good about responding and communicating with the facility. V2 stated that glucose readings obtained by finger prick in the facility are documented on the MAR (Medication Administration Record). V2 stated that no concerns had been brought to her attention which may suggest R3 was experiencing hyperglycemia prior to his May ER visit and hospitalization. V2 confirms it is her expectation that the facility immediately contacts the physician regarding any abnormal labs or change in resident status and document such communication. V2 confirmed that lab samples obtained are obtained in a fasting nature, as they are sure to have them drawn before breakfast. On 10/3/23 at 11:35 AM, V19 (Registered Nurse/RN) stated when a physician orders labs, they are obtained, and the physician is called if the results come back abnormal. V19 stated if the results are normal, they are placed in the resident's chart for review the next time the physician is in. V19 stated that all lab results are faxed to the physician office once the facility receives them so the physician can have a copy in their records. V19 stated that generally a note should be made in the resident's progress notes that the physician has been notified of any abnormal labs and any new orders, but you know how life goes. V19 stated prior to R3's hospitalization she cannot say R3 was experiencing any signs of hyperglycemia specifically due to his intermittent confusion making it hard to tell. On 10/3/23 at 11:46 AM, V20 (RN) stated that she was the staff member who sent R3 to the hospital in May for altered mental status. V20 stated the something was just off and R3 wasn't himself. V20 stated that she was doing an evaluation trying to figure out if there was something she could note being wrong. V20 stated R3's vital signs were normal, but a finger prick glucose test was taken and just read high. V20 stated that she repeated the test, again receiving the reading of high. V20 stated she notified V13 who gave orders to send R3 to the hospital for evaluation. V20 stated that when the hospital faxes the facility lab results from specimen draws, the nurse on duty reviews the labs and faxes all the labs to the physician. V20 stated if something is an abnormal level, the physician is notified immediately by phone. V20 stated that staff are suppose to make a progress note, documenting the physician communication. On 10/3/23 at 12:47 PM, V21 (Health Information at out-of-town hospital) stated that she is one staff member who worked with V13's office. V21 stated in reviewing R3's records they received from the nursing home, she can see where an A1c level dated 2/8/23 was faxed to V13's office. V21 stated the only lab values V13's office received from the facility dated 3/22/23 was a Vitamin B12 level. On 10/3/23 at 11:59 AM, V1 (Administrator) stated that a change in resident status or abnormal lab results should be communicated to the physician immediately with the communication documented in the progress notes of the resident record. V1 confirms that although requested, the facility is unable to provide communication with V13 immediately upon the receipt of R3's abnormal lab values from 2/8/23, 3/22/23, and 7/12/23. On 10/4/23 at 11:26 AM, V18 (Certified Nurse Assistant) stated she worked with R3 the day he was sent to the ED. V18 stated she recalls R3 urinating a lot that day and just being out of it. V18 stated that nursing staff were aware and were monitoring him. V18 stated she had taken his Vital Signs a couple times, and they were fine. R3's Clinical Record via paper and Electronic Health Record documented no immediate communication with V13 regarding the abnormal lab results from the 2/8/23, 3/22/23, and 7/12/23 specimens. R3's Medication Administration Record via paper and Electronic Health Record documented R3 was not having his glucose monitored via fingerstick, nor receiving any medication therapy for diabetes from 2/1/23 until 5/20/23, when R3 returned from the hospital. R3's current Active Orders as of 9/28/23 documented R3 receives blood glucose monitoring four times a day. R3 is documented as receiving subcutaneous insulin glargine and insulin aspart medications for treatment of diabetes mellitus. R3's Care Plan documented a problem area of Diabetes with an initiation date of 12/8/22. Interventions include obtaining labs as ordered, and physician notification as needed. 2. R19's admission record documents an admission date of 12/10/21. This same document includes the following diagnosis Type 2 Diabetes Mellitus. R19 has labs dated 8/23/23 with abnormal values compared to the reference range. These labs include an elevated glucose. At the bottom of the page an unsigned note written in 'faxed' and dated 8/23/23. No further documentation is found in the chart regarding following up with the physician to ensure labs were received and if any new orders are to be carried out. 3. R20's admission record documents an admission date as 6/26/22. This same document includes the following diagnosis: type 2 diabetes mellitus. R20's lab result dated 5/10/23 includes labs with abnormal ranges. These abnormal labs include an elevated glucose level. The lab results are dated 5/10/23 by V9 (LPN) as faxed to V13. On 10/5/23 at 11:30 AM, V9 stated that prior to 10/5/23 the policy was to just fax the lab results to the physician's office and no further documentation was done. The surveyor confirmed through interview and record review that the Immediate Jeopardy that began on 2/8/23 was removed on 10/5/23 when the facility took the following actions to remove the immediacy: 1) The Regional Director on 10/4/2023 in-serviced the Administrator, Director of Nurses (DON) and Assistant Director of Nurses (ADON) on the Notification for Change in Resident Condition or Status Policy and the Lab Policy and the importance of follow up on lab results and direct communication via telephone or during onsite provider visit until all licensed nurses are setup and trained on utilizing the secure communication app. 2) The Facility Director of Nursing, ADON and Administrator initiated in-servicing for all licensed nurses on 10/4/2023 on the Notification for Change in Resident Condition or Status Policy and the Lab Policy and directly communicating lab results on all residents as they are received. All nurses will be in-serviced by the nursing leadership prior to their next scheduled shift. 3) Facility QA team will complete a review audit of all labs received with regional clinical director on 10/5/2023. The Regional Director and Administrator verified with the Nurse Practitioner (NP) who was on site on Monday and Tuesday with the Nurse Practitioner that she has been notified of lab results and has communicated any changes to the (resident's) orders to staff. Her notes will also reflect any labs reviewed or new orders that were communicated with the staff. Nursing leadership will verify with the NP that all lab results have been promptly communicated with her. 4) R3's recent labs completed on 9/20/2023 have been reviewed and communicated to the physician. R3's labs were completely reviewed by physician at his previous visit on 8/7/2023 with no changes noted to be needed at that time and physician notes show that labs had been previously reviewed on his in-house visits to the facility. Two recent care plan meetings have been held with the family and resident (R3) regarding resident care needs with the most recent meeting having been completed on 10/2/2023. 5) Facility Administrator, DON, ADON and Regional Director initiated a facility wide lab audit on 10/4/2023 starting with requesting a list of all labs draws completed on 9/27/2023 from (local hospital) which was the last date labs were drawn at facility. 4 residents lab draws were completed, and the facility verified with NP who is on-site today that all current labs have been communicated directly and she's responded to those lab results. 6) Facility QA team is completing a lab audit going back to February 2023 to ensure that all lab results have been directly communicated to the physician and addressed and documented. Any further issues or abnormal labs noted in the lab and chart audit that facility staff cannot verify via documentation or physician notes will be relayed to the current provider to be addressed immediately and documentation completed. Lab audit of all 58 current in house residents is projected to be completed by 10/5/2023. 7) The following Quality Assurance programs have been implemented to ensure compliance: The facility DON, ADON or designee will complete a lab audit of all ordered and received labs for 4 weeks to ensure that all have been communicated with the physician and documentation is noted in resident chart. Regional Director or Regional Clinical Director will review the lab audit weekly with facility and make recommendations based on the outcome and review of the audit findings. The facility's QA team will review lab results daily at their Morning QA meeting as part of the review of the updated 24 hour report.