**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Quality Assurance Committee developed and implemented appropriate plans of action to correct identified quality deficiencies following identified errors in clarification and obtaining parameters of antidiabetic medication on admission orders for 1 (#RF2) of 6 (#F4, #RF1, #RF2, #RF3, #RF4, #RF5) residents selected for receiving antidiabetic medications. This deficient practice resulted in an immediate jeopardy situation for Resident #RF2 on 07/14/2023 when blood glucose parameters were not clarified or obtained from the physician for the order of insulin lispro subcutaneous 100 units/ml inject 7 units before meals. On 07/24/2023, Resident #RF2's blood glucose dropped from 102 to 58 after insulin lispro was administered. Resident #RF2 received 40 doses of subcutaneous insulin lispro without clarifying blood glucose parameters with a physician from 07/14/2023 to 07/28/2023. On 07/29/2023, the physician ordered to hold the insulin if the blood sugar was less than 150. Resident #RF2 was administered 9 doses of subcutaneous insulin lispro outside of physician's blood glucose parameters from 07/29/2023 to 08/03/2023 which had the likelihood of causing severe injury, harm or death if not immediately corrected. SF15ADM was notified of the Immediate Jeopardy situation on 08/04/2023 at 4:31 p.m. The Immediate Jeopardy was removed on 08/04/2023 at 9:00 p.m. when the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The Facility failed to ensure the Quality Assurance (QA) committee identified a quality deficiency and failed to monitor and evaluate the effectiveness of processes implemented in response to an appropriate plan of action to correct the deficient practices cited on the last complaint survey. The facility failed to have a system in place to ensure: Residents that received anti-diabetic medications had clarification of orders if blood glucose parameters were not present, Physician's orders were followed. 1. The orders for antidiabetic medications for Resident #RF2 were clarified by SF6RN on 08/03/2023 by SF3MD. 2. Any of the 22 residents receiving antidiabetic medications with parameters have the potential to be affected by the alleged deficient practice. 3. Systemic actions taken include the following: On 08/03/2023 Administrator and DON were educated by the Regional QI Nurse regarding the job duties and responsibilities associated with: 2 nurse verification of blood glucose value and verification of parameters prior to administering antidiabetic medications was put in place 08/03/2023. The Regional QI Nurse, educated SF1DON and SF2ADON, who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion date for training is 08/09/2023. If QA committee determines compliance is achieved, then the end date 09/15/2023. If Compliance is not achieved then 2 nurse verification of blood glucose value and verification of parameters prior to administering antidiabetic medications continue for another 6 weeks or longer, as determined by the QA Committee. Facility DON, Administrator, QI Nurse or the Clinical Care Coordinators have conducted a review of all Residents receiving antidiabetic medication to determine the following: Whether or not the antidiabetic medication was given following the MD orders with the parameters ordered. Completed 08/03/2023. The Regional QI Nurse, educated SF1DON and SF2ADON, who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion 08/09/2023. On 08/03/2023 education began Nurses on Diabetic Management which included the following: The Regional QI Nurse, educated SF1DON and SF2ADON, o who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion 08/09/2023. o Following Physician orders that include parameters: The Regional QI Nurse, educated SF1DON and SF2ADON, who in turn in-serviced nursing staff. Evaluation of learning is validated by verbal acknowledgement and post-test. Completion 08/09/2023. 1. 08/03/2023 Education for active nursing staff occurred on hovering over the see more option on the MAR to see additional details. This was done by the Director of Nurses: Completion date of 08/09/2023. 2. 2 nurse verification of blood glucose value and verification of parameters prior to administering antidiabetic medications was put in place 08/03/2023 at 7:01pm. Completion date of 08/09/2023. 3. DON and/or ADON will review execution of competencies of staff regarding Diabetic Management and following physician orders with parameters for residents on antidiabetic medications. completion 08/09/2023 o For future staff, any agency staff, or staff out on leave, or non-scheduled staff, they will receive all above listed education prior to working any scheduled shift. Facility staff and agency staff will not be allowed to work until the training is completed. Completion 08/09/2023. QAPI Committee members including but not limited to Administrator, DON and ADON, will review surveillance tools (2 Nurse Verification tool used to monitor accuracy of the amount of blood glucose value/given or held and verification of parameters, and the Execution of competencies of staff regarding Diabetic Management and following physician orders with parameters for residents on antidiabetic medications), 2 times per week for 6 weeks for compliance Start Date will be 08/08/2023 and end date will be 09/15/2023. If non-compliance is identified, then will restart education for staff and monitoring by QAPI Committee members will continue for another 6 weeks. 4. Administrator will review the implementation of the following: A. That a review of the residents with orders for antidiabetic medications with parameters are monitored by the DON/ADON to ensure ordered medications are delivered correctly beginning on 08/04/2023 and continuing 5 times per week for 2 weeks, and if continued compliance then 3 times per week for 4 weeks, and if continued compliance then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. If non-compliance identified, then will restart education and monitoring 5 times per week. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will monitor the Administrator and DON by reviewing the QA minutes weekly for completion and compliance. B. The completion of re-education, plan modification and progressive discipline as necessary, 5 times per week for 2 weeks, and if continued compliance then 3 times per week for 4 weeks, and if continued compliance then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. If non-compliance identified, then will restart education and monitoring 5 times per week. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will monitor the Administrator and DON by reviewing the QA minutes weekly for completion and compliance. C. QAPI Committee members including but not limited to Administrator, DON and ADON, will review surveillance tools (2 Nurse Verification tool used to monitor accuracy of the amount of blood glucose value/given or held and verification of parameters and the Execution of competencies of staff regarding Diabetic Management and following physician orders with parameters for residents on antidiabetic medications), and conduct at least 2 observations of anti-diabetic medication administration (4 per week), 2 times per week for 6 weeks for compliance Start Date will be 08/08/2023 and end date will be 09/15/2023. If non-compliance is identified, then will restart education for staff and monitoring by QAPI Committee members will continue for another 6 weeks. The deficient practice continued for more than minimal harm for the remaining residents identified by the facility as receiving antidiabetic medications Findings: Cross Reference F-726 Cross Reference F-867 Cross Reference F-684 Review of the Facility Policy titled Quality Assurance and Performance Improvement (QAPI) Program revealed the following, in part: Program: Each facility must develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life for our residents. Design and Scope At a minimum, the program must: Address all systems of care and management practices (which may include resident finances and personal funds, admission and discharge practices). Include clinical care, quality of life and resident choice. Utilize the best available evidence and performance indicators to measure of quality and facility goals. Implementation: The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Data collection for QAPI meetings should include, but is not limited to, infection control surveillance and tracking, infectious disease outbreaks, healthcare associated infections, antibiotic stewardship program related to antibiotic use and resistance data, wound logs, drug regimen reviews. Adverse events, use of antipsychotic medications, medical errors, incident and accident reports, cases of physical or sexual abuse, survey results, quality assurance and performance improvement projects. Adverse Events (3 categories- medication, care, and infection related) Thorough analysis as to why occurred. Implementation of corrective actions (define the problem, develop measurable goals, step by step interventions to correct the problem) Monitoring to ensure desired outcomes are achieved and sustained. Performance Improvement Projects: Interventions are designed to address the underlying causes, and once implemented, the team closely monitors results to determine if changes are yielding the expected improvement or if the interventions should be revised. Data Analysis, Monitoring and Feedback The QAPI process focuses on identifying systems and processes that may be problematic and could be contributing to avoidable negative outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making a good faith effort to correct or mitigate these outcomes. Data and information collected are reviewed by the committee and prioritized according to the risk, volume, and potential problems. It is not necessary to collect all data at the same frequency. The facility may develop a frequency reviewing high risk or problem prone areas more frequently until performance reached a satisfactory level, then collect data less frequently. Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as 80-130 mg/dL before meals Review of Resident #RF2's Nursing Facility Orders Dated 07/14/2023 at 3:24 p.m., revealed insulin lispro100 unit/ml 7 units subcutaneous 30 minutes before meals. No parameters for administration were noted or clarified. Further review of the two nurse verification of Resident #RF2's hospital discharge orders and nursing facility orders revealed signatures by SF2ADON and SF5MRLPN on 07/14/2023. Review of Resident #RF2's Fax Form for Non-Emergency Communication dated 07/28/2023 at 11:06 a.m. revealed, 07/28/2023, hold Insulin at meal times of blood sugar less than 150. Per SF4NP. Review of Resident #RF2's MARs from 07/14/2023 to 08/03/2023 revealed the following, in part: Start Date: 07/14/2023 Discontinue Date: 07/28/2023 Insulin lispro subcutaneous100unit/ml Inject 7 unit subcutaneously before meals. Start Date: 07/29/2023 Insulin lispro subcutaneous 100 units/ml Inject 7 unit subcutaneously before meals. Hold if blood sugar is less than 150. Review of the Resident #RF2's MAR from 07/14/2023 to 08/03/2023 revealed that Resident #RF2 received 40 doses of subcutaneous insulin lispro without blood glucose parameters from 07/14/2023 to 07/28/2023. Resident #RF2's MAR also revealed insulin lispro was administered 9 doses outside of physician's blood glucose parameters from 07/29/2023 to 08/03/2023. On 08/04/2023 at 12:55 p.m., an interview was conducted with SF1DON. SF1DON explained the facility had implemented a 2 check system for when orders were entered into the system for resident admissions and readmissions. SF1DON stated SF5MRLPN put the hospital orders for Resident #RF2 into the system but did not activate them. SF1DON stated SF2ADON reviewed the orders on 07/14/2023 for accuracy, activated them and they both signed off on the review. SF1DON stated SF5MRLPN no longer works at the facility. On 08/04/2023 at 1:00 p.m., an interview was conducted with SF2ADON. SF2ADON confirmed on 07/14/2023 she reviewed and activated an order for insulin lispro 7 units subcutaneously before meals. SF2ADON further confirmed she did not contact the physician for order clarification before the orders were activated. SF2ADON stated Resident #RF2 received insulin lispro 7 units subcutaneously from 07/14/2023 to 07/28/2023 without blood glucose parameters. SF2ADON stated on 07/28/2023 she notified the physician and orders were obtained for blood glucose parameters. SF2ADON stated she was not aware the facility implemented a procedure to clarify antidiabetic medications if blood glucose parameters were not specified in the physicians order. On 08/04/2023 at 1:05 p.m., an interview was conducted with SF1DON. SF1DON confirmed Resident #RF2 received insulin lispro 7 units subcutaneous from 07/14/2023 to 07/29/2023 without blood glucose parameters, and staff should have clarified the orders with the physician before the order was activated. On 08/04/2023 at 3:13 p.m., an interview was conducted with SF15ADM and SF1DON. The aforementioned findings were reviewed and confirmed with SF15ADM and SF1DON. SF15ADM stated Resident #RF2's subcutaneous insulin lispro orders should have been clarified regarding blood glucose administration parameters. SF15ADM stated staff should get clarification for insulin orders without blood glucose parameters on admission /re-admission. SF15ADM confirmed Resident #RF2 was admitted to the facility on [DATE] and the order was clarified on 07/28/2023, two weeks after his admission. SF15ADM stated MARs were checked daily for accuchecks and insulin administration. SF15ADM stated he did not know how SF2ADON missed this. SF15ADM confirmed their interventions for clarifying orders were not effective. SF15ADM confirmed the deficiencies with Resident #RF2 had not been identified and corrected in their QAPI. SF15ADM confirmed the facility was not in compliance on 07/13/2023 and there was no new QAPI opened or new measures implemented after 07/14/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure: 1. S5MRLPN reconciled and clarified Physician Orders upon admission and/or readmission to the facility for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalizations; and 2. S6RN, S7LPN, S8LPN, S9LPN and S14 LPN assessed and documented residents' blood glucose levels via accucheck prior to administering antidiabetic medications for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalizations. This deficient practice resulted in an immediate jeopardy situation for Resident #4, who had a diagnosis of Type II Diabetes, on the morning of [DATE], when the resident received the first dose of subcutaneous insulin without nursing staff assessing her blood glucose level. Upon admission to the facility on [DATE] from a local hospital, S5MRLPN failed to clarify Resident #4's hospital discharge Physician's Orders for insulin with no ordered accuchecks for blood glucose monitoring. Resident #4 received insulin twice daily from [DATE] through [DATE] without blood glucose monitoring and was transferred to the Emergency Department on the morning of [DATE] when she was found unresponsive. Resident #4's hospitalization was complicated by high doses of insulin at the nursing home and severe Hypoglycemia. The facility failed to identify and implement corrective actions upon Resident #4's return from the hospital to prevent this type of incident from reoccurring for other residents receiving antidiabetic medication who are admitted and/or readmitted to the facility. Then, on [DATE], Resident #2, returned to the facility from a local hospital with an order to restart Glimepiride 2 mg twice daily on [DATE] if oral intake had improved. Resident #2 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Resident #2 did not have orders for blood glucose monitoring. S5MRLPN failed to clarify the hospital discharge Physician's Orders and restarted Glimepiride 2 mg on [DATE] without verifying the parameters of improvement of oral intake or the need to implement blood glucose monitoring. Resident #2 received Glimepiride 2mg twice daily from [DATE] through [DATE]. Resident #2 was found unresponsive at 7:00 a.m. on [DATE] with a blood glucose reading of 31. Resident #2 was transferred to the hospital and diagnosed with Neuroglycopenia and widespread Cerebral Damage. Resident #2 expired on [DATE]. S15ADM and S1DON were notified of the Immediate Jeopardy on [DATE] at 3:07 p.m. The Immediate Jeopardy was removed on [DATE] at 8:35 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to follow, reconcile, and clarify physician orders. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Resident # 2 is currently not in the facility. The orders for insulin injections for Resident #4 were discontinued effective [DATE], upon readmission from the hospital. Resident #4 has active orders for CBG checks since [DATE], ordered by MD. Completion Date: [DATE]. Orders for monitoring Resident #4 for signs and symptoms of Hypoglycemia and Hyperglycemia were ordered by physician on [DATE]. Consultant Pharmacist completed a medication regimen review for Resident #4 on [DATE] with no new noted recommendations. Completion: [DATE] Nurse Practitioner visited Resident #4 on [DATE], progress notes include a review of current medications with no new orders to note. Completion Date: [DATE] Hgb A1C = 5.9% [DATE]. Completion: [DATE]. 2. New admissions and any residents readmitted to the facility have the potential to be affected by the alleged deficient practice. Facility DON and Administrator have conducted a review of all Residents with a diagnosis of Diabetes Mellitus to determine the following: Whether or not the resident is receiving an oral or injectable medication for Diabetes, Monitoring of CBGs have been ordered, Monitoring for signs and symptoms are in place for Hypoglycemia and Hyperglycemia have been ordered, Documentation of providing HS snacks is noted, and Whether or not resident is receiving an accucheck; if they do not have an accucheck ordered MD notified for recommendations. Completion: [DATE] On [DATE] Education for active nursing staff occurred on Diabetic Management by facility Director of Nurses. Completion: [DATE] On [DATE] Education for active nursing staff occurred on facility policy regarding medication reconciliation by Director of Nurses: Order entry is to be verified by 2 nurses. Any unclear orders or orders without parameters must be clarified with resident NP and/or MD. Completion: [DATE]. On [DATE] education for active nursing staff was completed regarding MD/NP notification of all admissions and readmissions by Director of Nurses. Completed: [DATE] Active Facility staff will be in-serviced on the Medication Regimen Review process for all admissions and readmissions. Medication orders and resident face sheets must be shared with the consultant pharmacist within 24 hours of admission or readmission. Begin Date: [DATE] and End Date: [DATE]. For future staff, any agency staff, or staff out on leave, they will receive all above listed education prior to working any scheduled shift. Facility staff and agency staff will not be allowed to work until the training is completed. 3. Systemic Actions taken by Facility include: New admissions and readmitted to the facility have the potential to be affected by the alleged deficient practice. Facility DON and Administrator have conducted a review of all Residents with a diagnosis of Diabetes Mellitus to determine the following: Whether or not the resident is receiving an oral or injectable medication for Diabetes, Monitoring of CBG's have been ordered, Monitoring for signs and symptoms are in place for Hypoglycemia and Hyperglycemia have been ordered, Documentation of providing HS snacks is noted, and Whether or not resident is receiving an accucheck; if they do not have an accucheck ordered, MD notified for recommendations. Completion [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. On [DATE] Education for active nursing staff occurred on Diabetic Management by facility Director of Nurses. Completion: [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. On [DATE] Education for active nursing staff occurred on facility policy regarding medication reconciliation by Director of Nurses Order entry is to be verified by 2 nurses. Any unclear orders or orders without parameters must be clarified with resident NP and/or MD. Completion: [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. On [DATE] education for active nursing staff was completed regarding MD/NP notification of all admissions and readmissions by Director of Nurses. Completed: [DATE]. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. Active Facility staff will be in-serviced on the Medication Regimen Review process for all admissions and readmissions. Medication orders and resident face must be shared with the consultant pharmacist within 24 hours of admission or readmission. Begin Date: [DATE] and End Date: [DATE] Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. For future staff, any agency staff, or staff out on leave, they will receive all above listed education prior to working any scheduled shift. Facility staff and agency staff will not be allowed to work until the training is completed. 4. Facility Director of Nurses and Assistant Director of Nursing will monitor compliance with plan of correction for all admissions and readmissions 5 times a week for 2 weeks, then 3 times a week for 4 weeks, and then as deemed necessary by QAPI committee. Begin date: [DATE], End date: [DATE]. This deficient practice continued at more than minimal harm for any residents admitting or readmitting to the facility on antidiabetic medications. Findings: Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Definitions: Diabetes is a disorder in which there is relative or absolute lack of insulin. Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as 80-130 mg/dL before meals 6. Approximate reference ranges for hypoglycemia are: c. Severe Hypoglycemia <40 mg/dL. Resident #4 Review of Resident #4's Clinical Record revealed a facility admission date of [DATE] and diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #4's 5-day MDS with an ARD of [DATE] revealed, in part, she had a BIMS of 13, which indicated she was cognitively intact. Review of Resident #4's current Care Plan revealed the following, in part: Problem: I have Diabetes Mellitus Interventions: Accuchecks per MD orders. Administer my diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #4's Physician Orders dated [DATE] revealed orders on [DATE] for Insulin Aspart Prot & Aspart 70/30 SQ 100unit/ml inject 42 units SQ daily in a.m. and 32 units SQ daily in p.m. related to Type II Diabetes Mellitus. The medication was started on [DATE]. Further review revealed no order for blood glucose monitoring. Review of Resident #4's Nurses' Notes dated [DATE] revealed, in part, no evidence the physician was notified to obtain an order for blood glucose monitoring. Review of Resident #4's MAR dated [DATE] revealed Insulin Aspart Prot & Aspart 70/30 SQ 100 unit/mL inject 42 units SQ in a.m. was started on [DATE]. The medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at a.m. medication pass by S6RN [DATE] at a.m. medication pass by S6RN [DATE] at a.m. medication pass by S6RN Further review of the [DATE] MAR revealed Insulin Aspart Prot & Aspart 70/30 SQ 100 unit/mL inject 32 units SQ in p.m. was started on [DATE]. This medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at p.m. medication pass by S14LPN [DATE] at p.m. medication pass by S6RN There was no documentation of blood glucose monitoring on the [DATE] MAR. Review of Resident #4's Vital Sign History from [DATE] through [DATE] revealed no documentation of blood glucose monitoring. Review of the Emergency Transfer Log from [DATE] through [DATE] revealed the following for Resident #4: Transfer date: [DATE] Location of transfer: local hospital Reason for transfer: low blood sugar Review of Resident #4's emergency room History and Physical Dated [DATE] revealed the following, in part: Type 2 Diabetes Mellitus with Stage 3b Chronic Kidney Disease, with long-term current use of insulin (HCC) Patient with history of Diabetes. On high doses of insulin at baseline with 42 units aspart in the morning and 32 units in the evening. -Hold all insulins for now. Hemoglobin A1C preserved at 6.4% -Monitor on sliding scale insulin -Hypoglycemia protocol ordered Review of Resident #4's Hospital Discharge summary dated [DATE] revealed the following, in part: Patient on high doses of insulin at her nursing home. Hospital course complicated by severe hypoglycemia requiring multiple rounds of D50. Recommend discontinuing all insulins for this patient as her A1C is preserved at 6.4 . An interview was conducted with S5MRLPN on [DATE] at 11:25 a.m. She stated Resident #4 admitted to the facility on [DATE] from a local hospital. She stated she was responsible for reconciling Physician Orders on admission and readmission. She stated Resident #4's hospital discharge orders were for twice daily Insulin Aspart 70/30 42 units in the a.m. and 32 units in the p.m. She confirmed she implemented the orders in Resident #4's electronic medical record. She stated the discharge orders did not list an order to obtain blood glucose monitoring. She stated Resident #4's physician should have been contacted to obtain orders for blood glucose monitoring. She confirmed Resident #4's physician was not notified of the insulin order without blood glucose monitoring ordered. An interview was conducted with S6RN on [DATE] at 1:01 p.m. She stated Resident #4 resided on the skilled hall, where she worked, at one time. She confirmed Resident #4 was on 70/30 insulin twice daily while on her unit and she sent her to the hospital one time for a low blood glucose level. She stated Resident #4 was unresponsive. She stated she administered Glucagon and Resident #4's blood glucose level continued to decline. She confirmed there were no documented blood glucose values for Resident #4 between [DATE] and [DATE] when she went to the hospital and there should have been. An interview was conducted with S1DON and S2ADON on [DATE] at 1:21 p.m. S2ADON reviewed Resident #4's medical record at that time. S2ADON confirmed Resident #4 did not have blood glucose monitoring ordered or documented from [DATE] through [DATE]. S1DON stated she would have expected the nurse who entered the insulin orders to consult with Resident #4's physician to obtain an order for blood glucose monitoring. S1DON stated she would have expected the nurses who administered insulin to Resident #4 to obtain and document blood glucose levels prior to administration. An interview was conducted with S3MD on [DATE] at 1:18 p.m. She stated any resident on insulin should have blood glucose monitoring. She stated she was not aware Resident #4 did not have an order for blood glucose monitoring from [DATE] through [DATE]. She stated if Resident #4 was discharged from the hospital with insulin orders and no blood glucose monitoring, she would have expected the nurse to notify her. An interview was conducted with S1DON on [DATE] at 11:05 a.m. She stated there was no system in place prior to survey entrance to check behind medical records and review hospital paperwork. Resident #2 Review of Resident #2's Clinical Record revealed she admitted to the facility on [DATE] and readmitted on [DATE]. Further review revealed Resident #2 had diagnoses which included Essential Hypertension, Type 2 Diabetes Mellitus with Hyperglycemia, Heart Failure, Unspecified Atrial Fibrillation, and Alzheimer's Disease. Review of Resident #2's Quarterly MDS with an ARD of [DATE] revealed, in part, she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #2's Care Plan revealed the following, in part: Problem: I have Diabetes Mellitus Goal: I will be free from any signs and symptoms of Hypoglycemia through the review date. Interventions: Accuchecks per MD orders. Administer my diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Review of Resident #2's Hospital Discharge Physician Orders dated [DATE] revealed the following, in part: Change how you take the following medications: Glimepiride (Amaryl) Prescribed Medication List: Glimepiride 2 mg tablet. Start taking on [DATE]. Take one tablet by mouth in the morning and one tablet before bedtime. Hold until PO intake improves. Review of Resident #2's Physician Orders dated [DATE] revealed the resident was prescribed accuchecks BID starting [DATE] through the discontinue date of [DATE]. Resident #2 was restarted on Glimepiride 2 mg PO BID on [DATE]. Further review revealed Accuchecks were not reordered and there were no instructions to hold Glimepiride until PO intake improved. Review of Resident #2's Meal Percentage Intake Documentation from [DATE] through [DATE] revealed the following: [DATE] at Breakfast - 0-25% Lunch - not documented Supper - not documented [DATE] at Breakfast - 51-75% Lunch - 51-75% Supper - 26-50% [DATE] at Breakfast - 0-25% Lunch - not documented Supper - 0-25% [DATE] at Breakfast - 26-50% Lunch - 26-50% Supper - 26-50% [DATE] at Breakfast - 26-50% Lunch - 26-50% Supper - 26-50% Review of Resident #2's MAR dated [DATE] revealed Glimepiride Tablet 2 mg BID was ordered on [DATE] and started on [DATE]. This medication was administered on the following dates, which was indicated by initials on the MAR. [DATE] at a.m. medication pass by S7LPN [DATE] at p.m. medication pass by S7LPN [DATE] at a.m. medication pass by S7LPN [DATE] at p.m. medication pass by S8LPN [DATE] at a.m. medication pass by S9LPN [DATE] at p.m. medication pass by S8LPN There was no documentation of blood glucose monitoring on the above dates. Review of Resident #2's Vital Sign Record dated [DATE] through [DATE] revealed the following Blood Glucose entry: [DATE] at 7:00 a.m. - 30 mg/dL by S9LPN Further review revealed no other entry between [DATE] through [DATE]. Review of Resident #2's Nurses' Notes for [DATE] revealed the following, in part: [DATE] at 8:01 p.m. by S10LPN: Resident readmitted to the facility from a local hospital. [DATE] at 9:38 a.m. by S9LPN: Upon performing daily blood glucose, resident was noted with a reading of 31. Unresponsive, shallow respirations of 14, periods of apnea for approximately 2-3 seconds then resident has a deep gurgling breath. Glucagon 1 mg administered at 7:00 a.m., recheck at 7:06 a.m. (34), recheck at 7:14 a.m. (40). Resident remains unresponsive and continues with short periods of apnea. Another gram of Glucagon administered. Resident remains unresponsive, glucose gel administered blood glucose 50. Resident remains unresponsive, EMS arrives checks blood glucose 54 . Transported at 7:30 a.m. via stretcher. Further review of the Nurse's Notes revealed no evidence Resident #2's physician was contacted for a clarification of the Glimepiride order or to obtain blood glucose monitoring. Review of Resident #2's Emergency Department Physician Notes dated [DATE] at 8:21 a.m. revealed the following, in part: Resident #2 presenting via EMS after being found unresponsive with unknown downtime. Patient was significantly hypoglycemic upon EMS arrival. Received Glucagon and was intubated enroute. GCS 3 on arrival and reported normal GCS 15. May have had some roaming eye movements versus subtle nystagmus. Upon recheck here glucose is still bit low, did administer Octreotide as she does have Glimepiride on her listed home medications. Also started glucose containing fluids. Consider possible Neuroglycopenia/Prolonged Hypoglycemia that may be contributing to her altered mental status and abnormal neuro exam. Right internal jugular central line was placed as noted below for continued administration of D10, venous access, and high-dose potassium for repletion. Review of Resident #2's ICU Physician Progress Note dated [DATE] revealed the following, in part: Assessment and Plan: Hypoglycemic Coma: Possibly due to Glimepiride and/or poor oral intake. Seizures: Likely due to Hypoglycemia. Being treated with Levetiracetam, Valproic Acid, Propofol, and Lacosamide. MRI indicates poor prognosis. Respiratory failure: Due to above. Review of Resident #2's Neurology Physician Progress Note dated [DATE] revealed the following, in part: Brief History and Physical: Impression: Neuroglycopenia Recommendations: - Due to the lack of patients studied with this condition, unable to give definite prognosis. Can say that her low blood sugar caused widespread cerebral damage. Can also say that her chance of having a meaningful recovery is probably 1 in 8. Recovery from Neuroglycopenia can take up to a year, for those that do recover. - Suggest trying to get family together and see if they can nominate someone to be decision maker. An interview was conducted with S11CNA on [DATE] at 10:36 a.m. She confirmed she took care of Resident #2 regularly and her appetite was poor since returning from the hospital on [DATE]. She stated she was assigned to Resident #2 on [DATE], and she ate less than 25% of breakfast and 75% of lunch. An interview was conducted with S12CNAS on [DATE] at 11:15 a.m. She stated when Resident #2 returned from the hospital on [DATE], her appetite had decreased. She stated Resident #2 ate less than 25% of most meals. She stated she was not consuming enough calories. An interview was conducted with S13CNA on [DATE] at 2:40 p.m. She confirmed she was assigned to Resident #2 on [DATE] from 2:00 p.m. to 6:00 a.m. She stated throughout her shift on [DATE], Resident #2 was sleepy. She stated she slept throughout her rounds and would only moan when she would turn her to change her brief. She stated Resident #2 refused supper on [DATE] and she reported this to the nurse. She stated Resident #2 did not wake up to consume snacks on her shifts on [DATE]. She reviewed Resident #2's documented meal intake and verified the documentation was inaccurate. She confirmed Resident #2 consumed 0% of her supper meal on [DATE]. She stated Resident #2 had consumed significantly less at meals and refused more meals since she returned from the hospital on [DATE]. An interview was conducted with S8LPN on [DATE] at 2:16 p.m. She stated she had been working at the facility for three weeks. She stated she worked the 2:00 p.m. to 10:00 p.m. shift on Resident #2's hallway. She stated Resident #2 never received blood glucose monitoring on her shift. She confirmed she administered Glimepiride to Resident #2 on the evening of [DATE]. She stated she was unaware Resident #2 did not eat her supper on [DATE]. She stated she was unaware Resident #2's Glimepiride should have been held until her intake improved. An interview was conducted with S9LPN on [DATE] at 9:42 a.m. She confirmed she was the nurse that sent Resident #2 to the hospital on the morning of [DATE]. She stated Resident #2's blood glucose level was 30 mg/dL and Resident #2 did not respond to any stimuli. She reviewed Resident #2's Medical Record and confirmed Resident #2 did not have an order for blood glucose monitoring after her return from the hospital on [DATE] and did not have blood glucose levels documented until [DATE] at 7:00 a.m. when it was 30 mg/dL. She confirmed on [DATE], Resident #2 began receiving Glimepiride 2 mg twice daily. She stated Resident #2's appetite was very poor. She stated Resident #2 ate on average 25-50% of meals. She stated Resident #2 frequently skipped meals. She stated Resident #2's appetite had decreased since her return from the hospital on [DATE]. She stated she was not aware Resident #2's Glimepiride should have been held until her appetite improved. She stated if she had known, she would have held Resident #2's Glimepiride and notified the physician. An interview was conducted with S5MRLPN on [DATE] at 11:40 a.m. She stated she reconciled Resident #2's physician orders per the discharge orders received from a local hospital on [DATE]. She stated the discharge orders did not list to obtain blood glucose monitoring, so she discontinued them. She stated she should have contacted Resident #2's physician to see if she wanted to continue blood glucose monitoring for Resident #2. She stated she entered the order for Glimepiride 2 mg twice daily on [DATE] to begin on [DATE]. She confirmed she did not add to hold the medication until Resident #2's appetite improved. She stated she should have reviewed Resident #2's meal intake and contacted Resident #2's physician to obtain a clarification to the Glimepiride order. She stated there was not a system in place for anyone to check physician orders behind her. An interview was conducted with S1DON on [DATE] at 12:07 p.m. She stated S5MRLPN reconciled Resident #2's physician orders upon return from the hospital on [DATE]. She confirmed Resident #2's discharge orders stated to resume Glimepiride 2mg BID on [DATE] if appetite improved. She stated that was subjective and she would have expected S5MRLPN to obtain clarification from Resident #2's physician prior to implementing the order. She stated Resident #2's meal intake should have been communicated with Resident #2's physician prior to the Glimepiride order being initiated. She stated Resident #2's blood glucose monitoring should not have been discontinued prior to consulting her physician. She confirmed there were no documented blood glucose levels in Resident #2's medical record from [DATE] until [DATE] at 7:00 a.m. when there was a reading of 30 mg/dL. She stated there was not a system in place to check physician orders behind S5MRLPN. An interview was conducted with S3MD on [DATE] at 12:12 p.m. She stated when Resident #2 returned from the hospital on [DATE], she would have expected the facility contact her about restarting Resident #2's blood glucose monitoring and she would have restarted them. She stated prior to initiating Resident #2's hospital discharge order for Glimepiride, she would have expected the facility to communicate Resident #2's meal intake with her to determine if she would have restarted the Glimepiride. She stated when Resident #2 was started back on Glimepiride, blood glucose monitoring should have been initiated. She stated none of Resident #2's hospital discharge orders were communicated with her upon Resident #2's return on [DATE]. She stated not re-starting Resident #2's blood glucose monitoring and starting Glimepiride with poor meal intake could have contributed to her hypoglycemic episode. A telephone interview was conducted with S4NP on [DATE] at 12:36 p.m. She stated Resident #2's hospital discharge orders were not communicated to her upon her return on [DATE]. She stated the facility staff should have sought clarification from her or S3MD prior to starting Resident #2 back on the Glimepiride to determine if her meal intake was adequate. She stated starting Resident #2 back on Glimepiride, not conducting blood glucose monitoring, and poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with Medical Records at a local hospital on [DATE] at 4:58 p.m. She stated Resident #2 expired on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure Licensed and Registered Nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility nursing staff failed to ensure: 1. S5MRLPN reconciled and clarified Physician Orders upon admission and/or readmission to the facility for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalizations; and 2. S6RN, S7LPN, S8LPN, S9LPN and S14 LPN assessed and documented residents' blood glucose levels via accucheck prior to administration of antidiabetic medications for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalizations. This deficient practice resulted in an immediate jeopardy situation for Resident #4, who had a diagnosis of Type II Diabetes, on the morning of 04/25/2023, when the resident received the first dose of subcutaneous insulin without nursing staff assessing her blood glucose level. Upon admission to the facility on [DATE] from a local hospital, S5MRLPN failed to clarify Resident #4's hospital discharge Physician's Orders for insulin with no ordered accuchecks for blood glucose monitoring. Resident #4 received insulin twice daily from 04/25/2023 through 04/26/2023 without blood glucose monitoring and was transferred to the Emergency Department on the morning of 04/27/2023 when she was found unresponsive. Resident #4's hospitalization was complicated by high doses of insulin at the nursing home and severe Hypoglycemia. The facility failed to identify and implement corrective actions upon Resident #4's return from the hospital to prevent this type of incident from reoccurring for other residents receiving antidiabetic medication who are admitted and/or readmitted to the facility. Then, on 06/15/2023, Resident #2, returned to the facility from a local hospital with an order to restart Glimepiride 2 mg twice daily on 06/18/2023 if oral intake had improved. Resident #2 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Resident #2 did not have orders for blood glucose monitoring. S5MRLPN failed to clarify the hospital discharge Physician's Orders and restarted Glimepiride 2 mg on 06/18/2023 without verifying the parameters of improvement of oral intake or the need to implement blood glucose monitoring. Resident #2 received Glimepiride 2mg twice daily from 06/18/2023 through 06/20/2023. Resident #2 was found unresponsive at 7:00 a.m. on 06/21/2023 with a blood glucose reading of 31. Resident #2 was transferred to the hospital and diagnosed with Neuroglycopenia and widespread Cerebral Damage. Resident #2 expired on 07/04/2023. S15ADM and S1DON were notified of the Immediate Jeopardy on 07/06/2023 at 3:07 p.m. The Immediate Jeopardy was removed on 07/06/2023 at 8:35 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The Facility failed to ensure licensed and registered nurses: 1. Had specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. 2. The facility nursing staff failed to reconcile, transcribe, clarify, document, and implement physician orders for Resident #2 and Resident #4. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Resident #4 with orders for insulin injections were discontinued on 04/28/2023 upon readmission from hospital. Resident #4 has active orders for CBG checks effective 05/04/2023; ordered by MD. Resident #2 is currently not in the facility. Completion date: 06/29/2023. 2. Residents admitted or readmitted to the facility have the potential to be affected by the alleged deficient practice. 3. Systemic actions taken include the following: A. On 07/06/2023 Administrator and DON were educated by the Regional Director of Operations regarding the job duties and responsibilities associated with: a. Competencies for licensed and registered nurses on diabetic care management. b. Medication reconciliation c. Clarification of med orders prior to administration Completed 07/06/2023. B. On 06/28/2023 Nurses were educated in Diabetic Management which included the following: a. The 2 types of Diabetes Mellitus: i. Type I (Insulin Dependent) ii. Type Il (Non-Insulin Dependent) b. Signs and Symptoms associated with Diabetes, including: Hyperglycemia (increased thirst, dry mouth, increased urination, headache, lethargy, restlessness, and loss of appetite. ii. Diabetic ketoacidosis (DKA) or hyperosmolar (nonkeotic) - (high blood sugar, ketones in the urine, nausea and/or vomiting, drowsiness, weakness, short/labored/rapid respirations abdominal pain, dehydration, diminished urine, sweet or fruity odor of breath, dry and/or flushed skin, decreased awareness/senses, loss of consciousness and/or coma.) c. Hypoglycemia (blood sugar below reference ranges) - (weakness, dizziness, or faintness, restlessness, and/or muscle twitching, Tachycardia (increased heart rate), pale/cool/moist skin, excessive perspiration, irritability, blurred/impaired vision, headaches, numbness of tongue, (more severe) stupor/unconsciousness and or convulsions and (more severe) coma. d. Complications Associated with Diabetes e. Management of Hypoglycemia f. Medication Management B. On 06/28/2023 Nurses were educated in Diabetic Management. Completed by DON on 07/01/2023. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. C. On 06/28/2023 Nurses were educated on Order Reconciliation - Order entry to be verified by (2) nurses. Unclear orders or orders without parameters must be clarified with MD/NP. Completed by DON on 07/01/2023. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. D. On 06/28/2023 Nurses were educated MD/NP Notification is required for all admission / Readmissions. Completed by DON on 07/01/2023. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. E. Beginning on 07/06/2023, medication regiment review will be completed on patients admitted and re-admitted to the facility within 24 hours, by the Consultant Pharmacist. F. On 06/29/2023 Pre-Test and Post-Test (including but not limited to: Diabetes defined, symptoms associated with diabetes, 2 types of diabetes, glucose monitoring, insulin administration and medications that can be utilized to manage diabetes mellitus) completed by licensed and registered nurses and given by DON; completed 07/01/2023. Licensed and Registered nurses on leave and/or agency staff will be educated upon the next scheduled shift. G. Policies have been reviewed and no changes were determined to be necessary. H. All active resident records will be reviewed by consultant pharmacist, nurse practitioner or designee with end date for 07/14/2023. I. DON and/or ADON will review execution of competencies of staff in regarding the reconciliation, transcription, clarification, documentation and implementation of physician orders including the implementation of blood glucose monitoring for residents on antidiabetic medications. 4. Administrator will review the implementation of the following: A. Medication regiment review will be completed by the Consultant Pharmacist on patients admitted and re-admitted to the facility within 24 hours. B. Resident Diabetic Monitoring (including receiving oral medications, insulin injections, monitoring for hypoglycemia, monitoring for hyperglycemia, monitoring HS is offered and monitoring whether order for accuchecks on any resident with Diagnosis of Diabetes.) C. and for the completion and for documentation of re-education, plan modification and progressive discipline as necessary, 5 times per week for 2 weeks, then 3 times per week for 4 weeks and then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will review the QA minutes for completion and compliance. Begin date: 07/06/2023, End date: 08/18/2023. This deficient practice continued at more than minimal harm for any residents admitting or readmitting to the facility on antidiabetic medications. Findings: Cross Reference F-684. Review of the facility's Policy titled, Competency of Nursing Staff revealed the following, in part: Policy Statement: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nurses employed (or contracted) by the facility will: b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care. Policy Interpretation and Implementation: 1. The staff development and training program is created by nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program: b. Any gaps in education or training that may be contributing to poor outcomes. d. A method to track, assess, plan, implement and evaluate the effectiveness of training 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care f. Basic nursing skills i. Medication management 6. Facility and resident-specific competency evaluations will include: d. Reviewing adverse events that occurred as an indication of gaps in competency; or e. Demonstrated ability to perform activities that are within the scope of practice an individual is licensed to perform. Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Definitions: Diabetes is a disorder in which there is relative or absolute lack of insulin. Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as 80-130 mg/dL before meals 6. Approximate reference ranges for hypoglycemia are: c. Severe Hypoglycemia <40 mg/dL. Resident #4 Review of Resident #4's Clinical Record revealed a facility admission date of 04/24/2023 and diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #4's Physician Orders dated April 2023 revealed orders on 04/24/2023 for Insulin Aspart Prot & Aspart 70/30 SQ 100unit/ml inject 42 units SQ daily in a.m. and 32 units SQ daily in p.m. related to Type II Diabetes Mellitus. The medication was started on 04/25/2023. Further review revealed no order for blood glucose monitoring. Review of the Insulin Mix 70/30 Package Insert/Product Label revealed the following, in part: Generic Name: Insulin Aspart Indications and Usage: - Novolog Mix 70/30 is a mixture of insulin aspart protamine and insulin aspart indicated to improve glycemic control in adult patients with diabetes mellitus. Dosage and Administration: Important Preparation and Administration Instructions: - Always check insulin labels before administration Dosage Recommendations: - Individualize the dosage of Insulin Mix 70/30 based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. - Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness - During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen: - Changes in an insulin regimen (e.g., insulin strength, manufacturer, type, injection site or method of administration) may affect glycemic control and predispose to hypoglycemia or hyperglycemia. Make any changes to a patient's insulin regimen under close medical supervision with increased frequency of blood glucose monitoring. Hypoglycemia: - Hypoglycemia is the most common adverse reaction of all insulins, including Novolog Mix 70/30. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death. Review of Resident #4's MAR dated April 2023 revealed Insulin Aspart Prot & Aspart 70/30 SQ 100 unit/mL inject 42 units SQ in a.m. was started on 04/25/2023. The medication was administered on the following dates, which was indicated by initials on the MAR. 04/25/2023 at a.m. medication pass by S6RN 04/26/2023 at a.m. medication pass by S6RN 04/27/2023 at a.m. medication pass by S6RN Further review of the April 2023 MAR revealed Insulin Aspart Prot & Aspart 70/30 SQ 100 unit/mL inject 32 units SQ in p.m. was started on 04/25/2023. This medication was administered on the following dates, which was indicated by initials on the MAR. 04/25/2023 at p.m. medication pass by S14LPN 04/26/2023 at p.m. medication pass by S6RN There was no documentation of blood glucose monitoring on the April 2023 MAR. Review of Resident #4's Vital Sign History from 04/24/2023 through 04/27/2023 revealed no documentation of blood glucose monitoring. Review of the Emergency Transfer Log from April 2023 through May 2023 revealed the following for Resident #4: Transfer date: 04/27/2023 Location of transfer: Local Hospital Reason for transfer: Low Blood Sugar Review of Resident #4's emergency room History and Physical Dated 04/27/2023 revealed the following, in part: Type 2 Diabetes Mellitus with Stage 3b Chronic Kidney Disease, with long-term current use of insulin (HCC) Patient with history of Diabetes. On high doses of insulin at baseline with 42 units aspart in the morning and 32 units in the evening. -Hold all insulins for now. Hemoglobin A1C preserved at 6.4% -Monitor on sliding scale insulin -Hypoglycemia protocol ordered Review of Resident #4's Hospital Discharge summary dated [DATE] revealed the following, in part: Patient on high doses of insulin at her nursing home. Hospital course complicated by severe hypoglycemia requiring multiple rounds of D50. Recommend discontinuing all insulins for this patient as her A1C is preserved at 6.4 . An interview was conducted with S5MRLPN on 06/28/2023 at 11:25 a.m. She stated she was responsible for reconciling Physician Orders on admission and readmission. She stated Resident #4 was admitted to the facility on [DATE] with hospital discharge orders for twice daily Insulin Aspart Prot & Aspart 70/30 42 units in the a.m. and 32 units in the p.m. She stated the discharge orders did not specify an order to obtain blood glucose monitoring. She confirmed a resident that received insulin should receive blood glucose monitoring. She confirmed she did not contact the physician to clarify the order. She confirmed she implemented the insulin orders without blood glucose monitoring for Resident #4. An interview was conducted with S6RN on 06/28/2023 at 1:01 p.m. She confirmed Resident #4 received Insulin Aspart Prot & Aspart 70/30 insulin while in her care. She reported, on 04/27/2023, Resident #4 was found to have a low blood glucose level. She stated she had to administer Glucagon due to the residents' blood glucose continuing to decline. She confirmed Resident #4 was transferred to the hospital due to low blood glucose. She stated insulin should not be given without first checking a blood glucose level. She stated she checked Resident #4's blood glucose before giving her insulin but did not document it. She confirmed there were no documented blood glucose values for Resident #4 between 04/25/2023 and 04/27/2023 when she went to the hospital and there should have been. An interview was conducted with S1DON and S2ADON on 06/28/2023 at 1:21 p.m. S2ADON reviewed Resident #4's medical record at that time. S2ADON confirmed Resident #4 did not have blood glucose monitoring ordered or documented from 04/24/2023 through 04/27/2023. S1DON stated she would have expected the nurse who entered the insulin orders to consult with Resident #4's physician to obtain an order for blood glucose monitoring. S1DON stated she would have expected the nurses who administered insulin to Resident #4 to obtain and document blood glucose levels prior to administration. An interview was conducted with S3MD on 06/28/2023 at 1:18 p.m. She stated any resident on insulin should have blood glucose monitoring. She stated she was not aware Resident #4 did not have an order for blood glucose monitoring from 04/24/2023 through 04/27/2023. She stated if Resident #4 was discharged from the hospital with insulin orders and no blood glucose monitoring, she would have expected the nurse to notify her. Resident #2 Review of Resident #2's Clinical Record revealed she admitted to the facility on [DATE] and readmitted on [DATE]. Further review revealed Resident #2 had diagnoses which included Type 2 Diabetes Mellitus with Hyperglycemia Review of Resident #2's Hospital Discharge Physician Orders dated 6/15/2023 revealed the following, in part: Change how you take the following medications: Glimepiride (Amaryl) Prescribed Medication List: Glimepiride 2 mg tablet. Start taking on June 18, 2023. Take one tablet by mouth in the morning and one tablet before bedtime. Hold until PO intake improves. Review of Resident #2's Physician Orders dated June 2023 revealed the resident was prescribed accuchecks BID starting 01/25/2022 through the discontinue date of 06/15/2023. Resident #2 was restarted on Glimepiride 2 mg PO BID on 06/18/2023. Further review revealed Accuchecks were not reordered and there were no instructions to hold Glimepiride until PO intake improved. Review of the Glimepiride tablet Package Insert/Product Label revealed the following, in part: Description: Glimepiride is an oral blood-glucose-lowering drug of the sulfonylurea class. Precautions: - General: - Hypoglycemia: All sulfonylurea drugs are capable of producing severe hypoglycemia. Proper patient selection, dosage, and instructions are important to avoid hypoglycemic episodes. Debilitated or malnourished patients, and those with adrenal, pituitary, or hepatic insufficiency are particularly susceptible to the hypoglycemic action of glucose-lowering drugs. Hypoglycemia is more likely to occur when caloric intake is deficient . Information for Patients: - Patients should be informed of the potential risks and advantages of AMARYL and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of blood glucose. The risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members. Laboratory Tests Fasting blood glucose should be monitored periodically to determine therapeutic response. Geriatric Use: - Elderly patients are particularly susceptible to hypoglycemic action of glucose-lowering drugs. In elderly, debilitated, or malnourished patients, or in patients with renal and hepatic insufficiency, the initial dosing, dose increments, and maintenance dosage should be conservative based upon blood glucose levels prior to and after initiation of treatment to avoid hypoglycemic reactions. Review of Resident #2's MAR dated June 2023 revealed Glimepiride Tablet 2 mg BID was ordered on 06/15/2023 and started on 06/18/2023. This medication was administered on the following dates, which was indicated by initials on the MAR. 06/18/2023 at a.m. medication pass by S7LPN 06/18/2023 at p.m. medication pass by S7LPN 06/19/2023 at a.m. medication pass by S7LPN 06/19/2023 at p.m. medication pass by S8LPN 06/20/2023 at a.m. medication pass by S9LPN 06/20/2023 at p.m. medication pass by S8LPN There was no documentation of blood glucose monitoring on the above dates. Review of Resident #2's Vital Sign Record Dated 06/15/2023 through 06/21/2023 revealed the following Blood Glucose entry: 06/21/2023 at 7:00 a.m. - 30 mg/dL by S9LPN Further review revealed no other entry between 06/15/2023 through 06/21/2023. Review of Resident #2's Emergency Department Physician Notes dated 06/21/2023 at 8:21 a.m. revealed the following, in part: Resident #2 presenting via EMS after being found unresponsive with unknown downtime. Patient was significantly hypoglycemic upon EMS arrival. Received Glucagon and was intubated enroute. GCS 3 on arrival and reported normal GCS 15. May have had some roaming eye movements versus subtle nystagmus. Upon recheck here glucose is still bit low, did administer Octreotide as she does have Glimepiride on her listed home medications. Also started glucose containing fluids. Consider possible Neuroglycopenia/Prolonged Hypoglycemia that may be contributing to her altered mental status and abnormal neuro exam. Right internal jugular central line was placed as noted below for continued administration of D10, venous access, and high-dose potassium for repletion. Review of Resident #2's ICU Physician Progress Note dated 06/25/2023 revealed the following, in part: Assessment and Plan: Hypoglycemic Coma: Possibly due to Glimepiride and/or poor oral intake. Seizures: Likely due to Hypoglycemia. Being treated with Levetiracetam, Valproic Acid, Propofol, and Lacosamide. MRI indicates poor prognosis. Respiratory failure: Due to above. Review of Resident #2's Neurology Physician Progress Note dated 06/25/2023 revealed the following, in part: Brief History and Physical: Impression: Neuroglycopenia Recommendations: - Due to the lack of patients studied with this condition, unable to give definite prognosis. Can say that her low blood sugar caused widespread cerebral damage. Can also say that her chance of having a meaningful recovery is probably 1 in 8. Recovery from Neuroglycopenia can take up to a year, for those that do recover. - Suggest trying to get family together and see if they can nominate someone to be decision maker. An interview was conducted with S8LPN on 06/27/2023 at 2:16 p.m. She stated she worked the 2:00 p.m. to 10:00 p.m. shift on Resident #2's hallway. She stated Resident #2 never received blood glucose monitoring on her shift. She confirmed she administered Glimepiride to Resident #2 on the evening of 06/20/2023. She stated she was unaware Resident #2 did not eat her supper on 06/20/2023. She stated she was unaware Resident #2's Glimepiride should have been held until her intake improved. An interview was conducted with S9LPN on 06/27/2023 at 9:42 a.m. She confirmed she sent Resident #2 to the hospital on the morning of 06/21/2023. She stated Resident #2's blood glucose level was 30 mg/dL and Resident #2 did not respond to any stimuli. She reviewed Resident #2's Medical Record and confirmed Resident #2 did not have an order for blood glucose monitoring and did not have blood glucose levels documented until 06/21/2023 at 7:00 a.m. when it was 30 mg/dL. She confirmed on 06/18/2023, Resident #2 began receiving Glimepiride 2 mg twice daily. She stated Resident #2's appetite was very poor. She stated Resident #2's appetite had decreased since her return from the hospital on [DATE]. She stated she was not aware Resident #2's Glimepiride should have been held until her appetite improved. She stated if she had known, she would have held Resident #2's Glimepiride and notified the physician. An interview was conducted with S5MRLPN on 06/27/2023 at 11:40 a.m. She stated she reconciled Resident #2's physician orders per the discharge orders received from a local hospital on [DATE]. She confirmed prior to the resident being hospitalized , she had an order for blood glucose monitoring, but the discharge orders dated 06/15/2023 did not list to obtain blood glucose monitoring. She stated since the new orders did not list blood glucose monitoring, she discontinued them. She stated she should have contacted Resident #2's physician to see if blood glucose monitoring should have been continued for Resident #2. She stated she entered the order for Glimepiride 2 mg twice daily on 06/15/2023 to begin on 06/18/2023. She confirmed she did not add to hold the medication until Resident #2's appetite improved. She stated she should have reviewed Resident #2's meal intake and contacted Resident #2's physician to obtain a clarification to the Glimepiride order. An interview was conducted with S1DON on 06/27/2023 at 12:07 p.m. She stated S5MRLPN reconciled Resident #2's physician orders upon return from the hospital on [DATE]. She confirmed Resident #2's discharge orders stated to resume Glimepiride 2mg BID on 06/18/2023 if appetite improved. She stated that was subjective and she would have expected S5MRLPN to obtain clarification from Resident #2's physician prior to implementing the order. She stated Resident #2's meal intake should have been communicated with Resident #2's physician prior to the Glimepiride order being initiated. She stated Resident #2's blood glucose monitoring should not have been discontinued prior to consulting her physician. She confirmed there were no documented blood glucose levels in Resident #2's medical record from 06/15/2023 until 06/21/2023 at 7:00 a.m. when there was a reading of 30 mg/dL. An interview was conducted with S3MD on 06/27/2023 at 12:12 p.m. She stated when Resident #2 returned from the hospital on [DATE], she would have expected the facility contact her about restarting Resident #2's blood glucose monitoring and she would have restarted them. She stated prior to initiating Resident #2's hospital discharge order for Glimepiride, she would have expected the facility to communicate Resident #2's meal intake with her to determine if she would have restarted the Glimepiride. She stated when Resident #2 was started back on Glimepiride, blood glucose monitoring should have been initiated. She stated none of Resident #2's hospital discharge orders were communicated with her upon Resident #2's return on 06/15/2023. She stated not re-starting Resident #2's blood glucose monitoring and starting Glimepiride with poor meal intake could have contributed to her hypoglycemic episode. A telephone interview was conducted with S4NP on 06/27/2023 at 12:36 p.m. She stated Resident #2's hospital discharge orders were not communicated to her upon her return on 06/15/2023. She stated the facility staff should have sought clarification from her or S3MD prior to starting Resident #2 back on the Glimepiride to determine if her meal intake was adequate. She stated starting Resident #2 back on Glimepiride, not conducting blood glucose monitoring, and poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with Medical Records at a local hospital on [DATE] at 4:58 p.m. She stated Resident #2 expired on 07/04/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure: 1. A system was in place to ensure Physicians' Orders were transcribed accurately and clarified prior to implementation for 2 (#2 and #4) of 3 (#2, #4, and #5) residents reviewed with hospitalizations; and 2. Licensed and Registered Nurses were competent to assess and document blood glucose levels prior to medication administration for 2 (#2 and #4) of 2 (#2 and #4) residents reviewed with a diagnosis of Diabetes Mellitus. This deficient practice resulted in an immediate jeopardy situation for Resident #4, who had a diagnosis of Type II Diabetes, on the morning of [DATE], when the resident received the first dose of subcutaneous insulin without nursing staff assessing her blood glucose level. Upon admission to the facility on [DATE] from a local hospital, S5MRLPN failed to clarify Resident #4's hospital discharge Physician's Orders for insulin with no ordered accuchecks for blood glucose monitoring. Resident #4 received insulin twice daily from [DATE] through [DATE] without blood glucose monitoring and was transferred to the Emergency Department on the morning of [DATE] when she was found unresponsive. Resident #4's hospitalization was complicated by high doses of insulin at the nursing home and severe Hypoglycemia. The facility failed to identify and implement corrective actions upon Resident #4's return from the hospital to prevent this type of incident from reoccurring for other residents receiving antidiabetic medication who are admitted and/or readmitted to the facility. Then, on [DATE], Resident #2, returned to the facility from a local hospital with an order to restart Glimepiride 2 mg twice daily on [DATE] if oral intake had improved. Resident #2 had a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. Resident #2 did not have orders for blood glucose monitoring. S5MRLPN failed to clarify the hospital discharge Physician's Orders and restarted Glimepiride 2 mg on [DATE] without verifying the parameters of improvement of oral intake or the need to implement blood glucose monitoring. Resident #2 received Glimepiride 2mg twice daily from [DATE] through [DATE]. Resident #2 was found unresponsive at 7:00 a.m. on [DATE] with a blood glucose reading of 31. Resident #2 was transferred to the hospital and diagnosed with Neuroglycopenia and widespread Cerebral Damage. Resident #2 expired on [DATE]. S15ADM and S1DON were notified of the Immediate Jeopardy on [DATE] at 3:07 p.m. The Immediate Jeopardy was removed on [DATE] at 8:35 p.m. after the provider presented an acceptable plan of removal. Through observation, interview and record review, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. Plan of Removal: The Facility failed to administer in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system and to ensure licensed and registered nurses were competent to provide quality care to meet the needs of each resident by failing to follow, reconcile, and clarify medication orders prior to administration. Administration failed to ensure an effective system was in place for: 1. Failed to obtain a physician order clarification for blood glucose monitoring for Resident #4 prior to the administration of SQ insulin injections. 2. Failed to reconcile discharge orders and obtain physician order clarification for blood glucose monitoring and adequate oral intake prior to administration of oral diabetic medications for Resident #2. Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 1. Resident # 4 with orders for insulin injections were discontinued on [DATE] upon readmission from hospital. Resident #4 has active orders for CBG checks effective [DATE]; ordered by MD. Resident #2 is currently not in the facility. Completion date: [DATE]. 2. Residents admitted or readmitted to the facility have the potential to be affected by the alleged deficient practice. 3. Systemic actions taken include the following: A. On [DATE] Administrator and DON were educated by the Regional Director of Operations regarding the job duties and responsibilities associated with: a. Competencies for licensed and registered nurses on diabetic care management b. Medication reconciliation c. Clarification of med orders prior to administration Completed [DATE]. B. On [DATE] Nurses were educated in Diabetic Management which included the following: a. The 2 types of Diabetes Mellitus: i. Type I (Insulin Dependent) ii. Type Il (Non-Insulin Dependent) b. Signs and Symptoms associated with Diabetes, including: i. Hyperglycemia (increased thirst, dry mouth, increased urination, headache, lethargy, restlessness, and loss of appetite. ii. Diabetic ketoacidosis (DKA) or hyperosmolar (nonkeotic) - (high blood sugar, ketones in the urine, nausea and/or vomiting, drowsiness, weakness, short/labored/rapid respirations abdominal pain, dehydration, diminished urine, sweet or fruity odor of breath, dry and/or flushed skin, decreased awareness/senses, loss of consciousness and/or coma.) c. Hypoglycemia (blood sugar below reference ranges) - (weakness, dizziness, or faintness, restlessness, and/or muscle twitching, Tachycardia (increased heart rate), pale/cool/moist skin, excessive perspiration, irritability, blurred/impaired vision, headaches, numbness of tongue, (more severe) stupor/unconsciousness and or convulsions and (more severe) coma. d. Associated with Diabetes e. Management of Hypoglycemia f. Medication Management Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. C. On [DATE] Nurses were educated on Order Reconciliation - Order entry to be verified by (2) nurses. Unclear orders or orders without parameters must be clarified with MD/NP. Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. D. On [DATE] Nurses were educated MD/NP Notification is required for all Admission/ Readmissions. Completed by DON on [DATE]. Staff out on leave and/or agency staff will be educated upon the next scheduled shift. E. Beginning on [DATE], medication regiment review will be completed on patients admitted and re-admitted to the facility within 24 hours, by the Consultant Pharmacist. F. Policies have been reviewed and no changes determined to be necessary. G. All active resident records will be reviewed by consultant pharmacist, nurse practitioner or designee with end date for [DATE] H. DON and/or ADON will review new physician orders and reconciliation of hospital discharges orders to ensure staff compliance. 4. Administrator will review the implementation of the following: A. Medication regiment review will be completed by the Consultant Pharmacist on patients admitted and re-admitted to the facility within 24 hours. B. Resident Diabetic Monitoring (including receiving oral medications, insulin injections, monitoring for hypoglycemia, monitoring for hyperglycemia, monitoring HS is offered and monitoring whether order for accu-checks on any resident with Diagnosis of Diabetes.) C. and for the completion and for documentation of re-education, plan modification and progressive discipline as necessary, 5 times per week for 2 weeks, then 3 times per week for 4 weeks and then as deemed necessary by the Regional Director of Operations and Regional QI Nurse. Findings will be reported to the QA Committee weekly for continued compliance. Regional Director of Operations and QI Nurse will monitor the Administrator and DON by reviewing the QA minutes weekly for completion and compliance. Beginning date: [DATE], End Date: [DATE]. This deficient practice continued at more than minimal harm for any residents admitting or readmitting to the facility on antidiabetic medications. Findings: Cross Reference F-684. Cross Reference F-726. Review of the facility's Policy titled, Competency of Nursing Staff revealed the following, in part: Policy Statement: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nurses employed (or contracted) by the facility will: b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care. Policy Interpretation and Implementation: 1. The staff development and training program is created by nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents. 2. The following factors are considered in the creation of the competency-based staff development and training program: b. Any gaps in education or training that may be contributing to poor outcomes. d. A method to track, assess, plan, implement and evaluate the effectiveness of training 4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: d. Person centered care f. Basic nursing skills i. Medication management 6. Facility and resident-specific competency evaluations will include: d. Reviewing adverse events that occurred as an indication of gaps in competency; or e. Demonstrated ability to perform activities that are within the scope of practice an individual is licensed to perform. Review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus revealed the following, in part: Definitions: Diabetes is a disorder in which there is relative or absolute lack of insulin. Symptoms Associated with Diabetes The following conditions and related symptoms are associated with diabetes: 3. Hypoglycemia (blood sugar below reference ranges) Glucose Monitoring: 1. The management of individuals with Diabetes Mellitus should follow relevant protocols and guidelines. 2. The physician will order the frequency of glucose monitoring. 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as 80-130 mg/dL before meals 6. Approximate reference ranges for hypoglycemia are: c. Severe Hypoglycemia <40 mg/dL. Resident #4 Review of Resident #4's Clinical Record revealed a facility admission date of [DATE] and diagnoses which included Type 2 Diabetes Mellitus. Review of the Emergency Transfer Log from [DATE] through [DATE] revealed the following for Resident #4: Transfer date: [DATE] Location of transfer: local hospital Reason for transfer: low blood sugar Review of Resident #4's emergency room History and Physical Dated [DATE] revealed the following, in part: Type 2 Diabetes Mellitus with Stage 3b Chronic Kidney Disease, with long-term current use of insulin (HCC) Patient with history of Diabetes. On high doses of insulin at baseline with 42 units aspart in the morning and 32 units in the evening. -Hold all insulins for now. Hemoglobin A1C preserved at 6.4% -Monitor on sliding scale insulin -Hypoglycemia protocol ordered Review of Resident #4's Hospital Discharge summary dated [DATE] revealed the following, in part: Patient on high doses of insulin at her nursing home. Hospital course complicated by severe hypoglycemia requiring multiple rounds of D50. Recommend discontinuing all insulins for this patient as her A1C is preserved at 6.4 . Resident #2 Review of Resident #2's Clinical Record revealed she admitted to the facility on [DATE] and readmitted from a local hospital on [DATE]. Further review revealed Resident #2 had diagnoses which included Type 2 Diabetes Mellitus. Review of the facility's Emergency Transfer Log dated [DATE] revealed the following entries for Resident #2: Location of Transfer: Local Hospital, Transfer Date: [DATE], Return to Facility Date: [DATE] Location of Transfer: Local Hospital, Transfer Date: [DATE], Return to Facility Date: blank, Reason for Transfer: Unresponsive Review of Resident #2's Emergency Department Physician Notes dated [DATE] at 8:21 a.m. revealed the following, in part: Resident #2 presenting via EMS after being found unresponsive with unknown downtime. Patient was significantly hypoglycemic upon EMS arrival. Received Glucagon and was intubated enroute. GCS 3 on arrival and reported normal GCS 15. May have had some roaming eye movements versus subtle nystagmus. Upon recheck here glucose is still bit low, did administer Octreotide as she does have Glimepiride on her listed home medications. Also started glucose containing fluids. Consider possible Neuroglycopenia/Prolonged Hypoglycemia that may be contributing to her altered mental status and abnormal neuro exam. Right internal jugular central line was placed as noted below for continued administration of D10, venous access, and high-dose potassium for repletion. Review of Resident #2's Neurology Physician Progress Note dated [DATE] revealed the following, in part: Brief History and Physical: Impression: Neuroglycopenia Recommendations: - Due to the lack of patients studied with this condition, unable to give definite prognosis. Can say that her low blood sugar caused widespread cerebral damage. Can also say that her chance of having a meaningful recovery is probably 1 in 8. Recovery from Neuroglycopenia can take up to a year, for those that do recover. - Suggest trying to get family together and see if they can nominate someone to be decision maker. An interview was conducted with S1DON on [DATE] at 12:07 p.m. She stated S5MRLPN reconciled Resident #2's physician orders upon return from the hospital on [DATE]. She confirmed Resident #2's discharge orders stated to resume Glimepiride 2mg BID on [DATE] if appetite improved. She stated she would have expected S5MRLPN to obtain clarification from Resident #2's physician prior to implementing the order. She stated Resident #2's meal intake should have been communicated with Resident #2's physician prior to the Glimepiride order being initiated. She stated Resident #2's blood glucose monitoring should not have been discontinued prior to consulting her physician. She confirmed there were no documented blood glucose levels in Resident #2's medical record from [DATE] until [DATE] at 7:00 a.m. when there was a reading of 30 mg/dL. She stated there was no system in place to check orders behind S5MRLPN. An interview was conducted with S1DON on [DATE] at 3:18 p.m. She stated she was not aware of the issues with Resident #2's Glimepiride order and blood glucose monitoring prior to this morning when Resident #2's paperwork was requested. She stated she reviewed the documentation once it was requested and realized there was a problem. An interview was conducted with S1DON and S2ADON on [DATE] at 1:21 p.m. S2ADON reviewed Resident #4's medical record at that time. S2ADON confirmed Resident #4 did not have blood glucose monitoring ordered or documented from [DATE] through [DATE] and received insulin twice daily beginning [DATE]. S1DON stated she would have expected the nurse who entered the insulin orders to consult with Resident #4's physician to obtain an order for blood glucose monitoring. S1DON stated she would have expected the nurses who administered insulin to Resident #4 to obtain and document blood glucose levels prior to administration. An interview was conducted with S3MD on [DATE] at 12:12 p.m. She stated when Resident #2 returned from the hospital on [DATE], she would have expected the facility contact her about restarting Resident #2's blood glucose monitoring and she would have restarted them. She stated prior to initiating Resident #2's hospital discharge order for Glimepiride, she would have expected the facility to communicate Resident #2's meal intake with her to determine if she would have restarted the Glimepiride. She stated when Resident #2 was started back on Glimepiride, blood glucose monitoring should have been initiated. She stated none of Resident #2's hospital discharge orders were communicated with her upon Resident #2's return on [DATE]. She stated not re-starting Resident #2's blood glucose monitoring and starting Glimepiride with poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with S3MD on [DATE] at 1:18 p.m. She stated any resident on insulin should have blood glucose monitoring. She stated she was not aware Resident #4 did not have an order for blood glucose monitoring from [DATE] through [DATE]. She stated if Resident #4 was discharged from the hospital with insulin orders and no blood glucose monitoring, she would have expected the nurse to notify her. A telephone interview was conducted with S4NP on [DATE] at 12:36 p.m. She stated Resident #2's hospital discharge orders were not communicated to her upon her return on [DATE]. She stated the facility staff should have sought clarification from her or S3MD prior to starting Resident #2 back on the Glimepiride to determine if her meal intake was adequate. She stated starting Resident #2 back on Glimepiride, not conducting blood glucose monitoring, and poor meal intake could have contributed to her hypoglycemic episode. An interview was conducted with S1DON on [DATE] at 11:05 a.m. She stated there was no system in place to check behind medical records order entries and to review hospital paperwork. She stated there was no system in place to review a resident's hospital course, including history and physicals and progress notes, to identify any deficient practice and/or errors in order entry, reconciliation, and clarification. She stated she was not aware Resident #4 had any hypoglycemic complications during her hospital stay from [DATE] through [DATE]. She stated she was not aware of Resident #4 not having blood glucose monitoring ordered from [DATE] through [DATE] until surveyor brought it to her attention. An interview was conducted with S15ADM on [DATE] at 11:30 a.m. He stated he was not aware of the issues with Resident #2 and Resident #4's orders, glucose monitoring, and medication administration. He stated the facility should have had a system in place to identify these concerns with Resident #2 and Resident #4.