**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to initiate orders to conduct blood sugar levels on a newly admitted resident with a significant history of Type 1 Diabetes Mellitus and was receiving insulin, for 1 (#4) of 5 (#1-5) sampled residents, and 7 (R1-R7) randomly selected residents. This deficient practice resulted in an immediate jeopardy for Resident #4 on 08/16/2023 when he was admitted to the facility until 08/18/2023 when he was transferred to the hospital via ambulance. On 08/16/2023, the resident was admitted with a significant history of Type 1 Diabetes Mellitus, including a Right Below the Knee Amputation, a recent diagnosis of Diabetic Ketoacidosis, Diabetic foot ulcers, and Gangrene. On 08/18/2023 Resident #4 became sluggish, lethargic, and short of breath. A glucometer level was obtained at that time, with the level too high to be read. Resident #4 was hospitalized on [DATE] with a blood glucose level of 814. He was admitted to the ICU (Intensive Care Unit) with diagnosis the included Diabetic Ketoacidosis without coma associated with Type 1 Diabetes Mellitus, and AKI (Acute Kidney Injury) Acute. Resident #4 was hospitalized from [DATE] through 08/24/2023. The facility implemented corrective actions and was in substantial compliance on 08/21/2023, prior to the State Agency's survey, thus it was determined to be a Past Noncompliance citation. Findings: A review of the nursing facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus was conducted. The policy included, in part: Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications, and the principals of glucose monitoring. 1. Hyperglycemia uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia. 2. Diabetic Ketoacidosis (DKA) (diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated and the cells begin to metabolize fat for energy. DKA is a life threatening emergency that needs immediate medical attention. The policy included: Blood Glucose Monitoring: 3. for the resident receiving insulin who is well controlled. Monitor blood glucose levels twice a day if on insulin. The policy did not include a protocol for blood glucose monitoring of a resident receiving insulin who was not well controlled. A review of a document titled New Admit/Readmit Checklist revealed: CBG (Capillary Blood Glucose) check daily x 7 days on new admits. A review of hospital documentation in Resident #4's nursing home chart revealed that on 08/16/2023, Resident #4 was discharged from the hospital to the nursing home. Diagnoses included Resolved- Diabetic Ketoacidosis without coma associated with Diabetes Mellitus Type 1, Right left Below the Knee Amputation, (BKA), Gangrene of toe Right foot, Lower Limb Ischemia, Peripheral Artery Disease, Anxiety, Chronic Systolic Heart Failure, Coronary Artery Disease, Diabetes Mellitus Type 1, and Diabetic Ulcer of Left Great Toe. Resident #4's medications included an order for Insulin -Lantus 100 u/ml (units per milliliter). 25 units in the morning. Further review revealed Resident #4's Blood glucose levels while in the hospital ranged as follows: 08/07/23- elevated at 523 mg/dL (milligrams per deciliter), 08/08/23 elevated at 340, 357, and 401 mg/dl. 08/15/23 low at 43 mg/dl. No ranges were noted on the hospital lab results. The Mayo Clinic states that a normal blood sugar level for a Type 1 diabetic ranges between 80 and 130 mg/dL before meals and no higher than 180 mg/dL after eating. Source: Mayo Clinic: Diabetes Conditions and Treatment, May 3, 2023. Review of Resident #4's nursing home record confirmed an admission date of 08/16/2023 with diagnoses including Disorder of Circulatory System, Malnutrition, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, and Acute Metabolic Acidosis. A review of Resident #4's Care Plan revealed the following: 08/16/2023: I suffer from DM II (Diabetes Mellitus Type 2); I suffer from diabetic neuropathy and diabetic ulcers; I have history of hyperglycemia (high blood sugar) and DKA (Diabetic Ketoacidosis). Interventions included: CBGs (Capillary Blood Glucose) (accuchecks) as ordered and PRN (as needed); Monitor me for s/s (signs and symptoms) of hyper polyuria, thirst, restlessness, agitation, confusion; Monitor me for complications such as decreased healing, decreased circulation. A review of handwritten admission orders dated 08/16/2023, signed by S1MD and S4LPN was conducted. An order for Lantus insulin 25 units administered Q AM (every morning) was noted. Further review of the orders revealed no order for CBG's to be conducted on Resident #4. A review of the August 2023 printed orders and telephone orders revealed the following: 08/16/2023-Lantus (insulin glargine) inject 25 u (units) sq (subcutaneously) one time a day. There was no order for CBG testing. 08/18/2023-Lantus 27 u sq one time a day. 08/18/2023 CBG's AC/HS (before meals and before sleep) with Humalog sliding scale related to type 2 diabetes mellitus with diabetic polyneuropathy. S4LPN's signature was noted; 08/18/2023 Give 12 u Lispro now recheck CBG. S5LPN's signature was noted; 08/18/2023 give 5 u Lispro now recheck CBG in 30 minutes. S5LPN's signature was noted; 08/18/2023- Send to ER for DX (Diagnosis) hyperglycemia. CBG unable to read. S5LPN's signature was noted. A review of Resident #4's MAR (Medication Administration Record) revealed the Humalog insulin order dated 08/18/2023. Lantus 25 u was administered on 08/18/2023 at 8:00 a.m. The documentation for BS (Blood Sugar) was 400 at 5:00 p.m., and 8:00 p.m., by S5LPN. Lispro 5 u and 12 u were administered by S5LPN on 08/18/2023 as ordered. The BS readings were recorded as 400 for both Lispro administrations. A review of Resident #4's Progress Notes revealed the following: 08/18/2023 at 3:11 p.m. New order per S1MD. CBG AC/HS with sliding scale. Signed by S4LPN; 08/18/2023 at 3:39 p.m. CBG was HI on reading by S5LPN; 08/18/2023 at 4:42 p.m. Res (resident) appears sluggish, CBG checked reads hi. New order noted give 12 u per s/s (sliding scale) by S5LPN; 08/18/2023 at 4:43 p.m. CBG checked reading show hi. New order give 5 units of s/s and recheck in 30 minutes by S5LPN; 08/18/2023 at 5:36 p.m. Greater than 400 by S5LPN; 08/18/2023 at 5:37 p.m. Not given send to ER for hypoglycemia [Sic.] by S5LPN. A review of a document titled Transfer To Other Facility Or Hospital, dated 08/18/2023 was conducted. The document included: Situation 1. Hyperglycemia. CBG unable to read to high. A review of the Emergency Department notes dated 08/18/2023 at 6:30 p.m., was conducted. The History included that the patient presented with Hyperglycemia- was given 12 units Lispro at nursing home, reports CBG still elevated .persistent glucose elevation greater than 600 was given 12 units of Lispro at the nursing home but no change to his glucose levels. Blood sugar level PTA (prior to arrival) 600, Diabetic status: controlled with insulin. Risk factors: History of DKA. Critical Care: Comments included: elevated glucose levels, labs consistent with acute DKA given depressed bicarb levels elevated glucose greater than 800. Started on DKA protocol and admitted to the ICU. Comprehensive metabolic panel: glucose level 814. Diagnosis: 1. Diabetic Ketoacidosis without coma associated with Type 1 Diabetes Mellitus; 2. AKI (Acute Kidney Injury) Acute. A review of a Grievance/Complaint Form dated 08/21/2023 for Resident #4 revealed a complaint that the resident was not getting insulin/CBG checks. The Investigation Findings revealed orders written for CBG/Accuchecks. CBG taken and meds administered per orders. Follow Up Action Taken included: Admissions nurse counseled on obtaining correct orders. The documentation included a Physician's Telephone Order dated 08/18/2023 that included: CBG AC & HS Humalog SS; Lantus 27 units SQ daily. The order was signed by S5LPN. A Notice of Disciplinary Action dated 08/21/2023 with employee name S4LPN noted. The form included: Rule violation-upon admit accuchecks was not initiated. Upon admit any res with DX of DM (Diabetes Mellitus) will have orders for accuchecks with sliding scale to create a baseline for MD (Medical Doctor) to review. The form was dated 08/21/2023 and signed by both S4LPN and S3RN/QA (Quality Assurance). An Inservice Record dated 08/21/2023 signed by S4LPN was noted. The inservice included: Upon admission, if a resident has a diagnosis of Diabetes Mellitus please refer to providers standing orders for accuchecks and sliding scales. All residents are required to have accuchecks with sliding scale to develop a baseline for MD review. An assessment dated [DATE] conducted by S1MD of Resident #4 was reviewed. The assessment included a review of problems, which included Type 1 diabetes mellitus uncontrolled, and Metabolic Acidosis. Further review of S1MD's assessment revealed the following: He has a medical history significant of type 1 diabetes. He was initially admitted and required transfer back to the hospital within about 24-48 hours. During his readmission he was treated for hyperglycemia, diabetic ketoacidosis. On 08/29/2023 at 11:55 a.m., an observation and interview were conducted with Resident #4. He was aphasic and a family member spoke on his behalf. The family member stated that he was admitted to the nursing home from the hospital on [DATE]. He stated that on the afternoon of 08/18/2023 he reported to the nurse that the resident was sluggish, lethargic and was having a hard time breathing, and that he was a brittle diabetic and asked what the resident's accuchecks had been reading. They stated that nursing home staff had not checked his sugar until that time. He stated that the staff were administering insulin to him from 08/16/2023 through 08/18/2023 but were not checking his blood sugars. On 08/18/2023 he spoke to S5LPN regarding the resident's blood sugar and the nurse reported that they did not have an order to conduct blood sugars on the resident so they had not been checking it since his admit on 08/16/2023. The family member stated that S5LPN took his blood sugar but it was so high that it did not register a number on the glucometer. They stated that Resident #4 was sent to the ER and then admitted to the ICU (Intensive Care Unit) and that his sugar was over 800. He was in the hospital from [DATE] to 08/24/2023. Resident #4 nodded his head in agreement with his family's account. On 08/29/2023 at 2:45 p.m., an interview was conducted with S5LPN. She stated that Resident #4 was admitted on [DATE], and confirmed that he had a diagnosis of Diabetes Mellitus. She stated that no order for a CBG had been initiated upon his admission and that staff had not conducted blood glucose checks on the resident from 08/16/2023 to 08/18/2023 because there was no order. S5LPN stated that on 08/18/2023, the resident was sluggish and an order for CBG/Accuchecks was received. She stated that the reading on the glucometer on 08/18/2023 was too high to be read. She confirmed that documentation of 400: on the MAR, and clarified that this indicated it was too high to read. S5LPN confirmed that she documented on the transfer form that CBG was too high to be read and they sent Resident #4 to the ER related to hyperglycemia. On 08/29/2023 at 4:30 p.m., an interview was conducted with S2DON. She stated that a plan was put into place to correct lack of CBGs being conducted on Resident #4. She stated that as a result of the CBG's not being conducted, the admissions nurse will follow a new admit/readmit checklist that included that CBGs will be checked daily for 7 days on the new residents. S2DON stated that new or readmitted residents who have a Diabetes diagnosis and are receiving insulin will have CBG's ordered AC/HS for 7 days. On 08/30/2023 at 10:30 a.m., an interview was conducted with S4LPN, who stated that she was the admissions nurse for the nursing home. S4LPN reviewed her handwritten admission orders profile dated 08/16/2023 for Resident #4 and the hospital documentation she transcribed her orders from. She stated that she reviewed all Resident #4's diagnoses, orders, and medications with S1MD. S4LPN confirmed that she had discussed the diagnoses listed on the hospital admission packet including Diabetic ketoacidosis without coma associated with Type 1 Diabetes Mellitus, Right Below Knee Amputation, Diabetes Mellitus, Diabetic Ulcer of Left Great Toe, Gangrene of toe of Right Foot, Lower Limb Ischemia, Peripheral Arterial Disease, Anxiety, Chronic Systolic Heart Failure, and Coronary Artery Disease. She made him aware of the order for the insulin Lantus 25 units q day. She further stated that if S1MD had made any additional orders for Resident #4, including conducting CBG checks on him, she would have written them down. She stated he had not given her an order to conduct CBG checks on the resident. S4LPN stated that S1MD was aware that no CBG's had been ordered on 08/16/2023 when the resident was admitted . She stated that since this situation with Resident #4, S2DON had initiated a procedure to conduct CBGs on all new residents and on readmitted residents. She stated that staff will conduct CBGs AC & HS for 7 days on residents who are have diabetes and are receiving insulin if they don't have orders on admission. S4LPN stated that on 08/18/2023, she overheard Resident #4's family speaking to the nurse at the nurse's station about the CBGs. The family member stated that the nursing home staff needed to be doing the CBG's as the resident was a severe diabetic and when she heard that, it was a red flag to her. She stated that she texted S1MD and got an order from him for CBG's AC and HS to be conducted on Resident #4. On 08/30/2023 at 2:00 p.m., a telephone interview was conducted with S1MD. He stated that when Resident #4 was admitted to the nursing home, the admission nurse called him and they reviewed all the orders, medications, and diagnosis. He confirmed that the only assessment he had conducted on Resident #4 was on 08/29/2023 as the resident was sent out to the hospital shortly after he was initially admitted , and before he (S1MD) was able to see him. This surveyor read the diagnoses from the admission paperwork dated 08/16/2023, from the admitting hospital, and that Resident #4 was receiving the insulin Lantus. S1MD stated that he was aware of all the Resident's diagnoses and that he had been receiving insulin. He further stated that he was aware that no accuchecks had been ordered for the resident from the discharging hospital. S1MD stated that the hospital had discharged the resident to the nursing home with no accuchecks ordered and he saw no reason to add accuchecks to the orders for this resident. He stated that nothing that the admission nurse from the nursing home informed him about the resident, including the diagnoses, made him consider changing any of the orders from the hospital including adding accuchecks for the resident. S1MD stated that If the hospital felt he was stable for discharge to the nursing home, and wrote those orders, why would I add to them? S1MD confirmed that he had been made aware that on 08/18/2023 the resident's Blood Glucose/Accucheck readings were too high for the glucometer to read, and that upon admission to the hospital on [DATE] his blood glucose was over 800. S1MD further stated that he did not think the nursing home staff should have been conducting Accuchecks on the resident when he was admitted on [DATE]. On 08/30/2023 at 4:07 p.m., an interview was conducted with S2DON. She was asked if the nursing home should have been conducting CBG's on Resident #4 between 08/16/2023 and 08/18/2023, when he was admitted and before he became symptomatic and had to be sent out to the hospital due to hyperglycemia on 08/18/2023. S2DON stated they were following the discharge orders from the hospital and the orders did not include CBGs. S2DON further stated that S1MD had not ordered CBGs on the resident, and that S4LPN followed the hospital orders. Review of in-services during the survey revealed the following Corrective Action Plan was implemented. A review of residents admitted from 08/21/2023 revealed that CBG's had been ordered and conducted appropriately. Interviews with multiple nursing staff verified that they were in-serviced and were conducting CBGs per the corrective action plan. The facility had implemented the following actions to correct the deficient practice and was in the process of in servicing all nursing staff with substantial compliance accomplished on 08/21/2023. 08/21/2023- Continuous Quality Assessment and Improvement Corrective Action Plan was initiated: 08/21/2023- In-service conducted for the admission nurse to ensure CBG's/Accuchecks were conducted on any resident with a diagnosis of Diabetes Mellitus; 08/21/2023- A New Admit/Readmit Checklist including CBG checks daily x 7 days on all new admits; 08/29/2023- In-service conducted with nursing staff on signs and symptoms of Hyperglycemia, new admits with a Diabetes diagnosis and/or order of insulin, clarify need of order for accuchecks as needed with NP or MD. 08/29/2023- In-service conducted with nursing staff on signs and symptoms of Hypoglycemia; and Monitoring of CBG orders for new/readmitted residents ongoing from 08/21/2023 for 12 weeks by QA nurse.