**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (NY00309249) the facility did not ensure the physician reviewed the total program of care, including medications and treatments, for one (1) of four (4) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge orders included routine short-acting insulin and sliding scale (the amount of insulin administered was based on the results of blood glucose finger sticks) short-acting insulin. The resident did not have admission orders for routine short-acting insulin and sliding scale short-acting insulin as recommended. Subsequently, Resident #1 was hospitalized for hyperosmolar hyperglycemic state (severely high blood glucose levels with severe dehydration and confusion). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Findings include: The facility policy, Transcription of Orders, was issued 1/2024, after the incident. There were no transcription policies available for 2023. Resident #1 had diagnoses including type 2 diabetes (the body does not use insulin effectively or does not produce enough insulin) and multiple sclerosis (a central nervous system disease). The admission Minimum Data Set assessment was not completed prior to the resident's discharge to the hospital on 1/21/2023. The hospital physician Discharge summary dated [DATE] at 2:42 PM, documented the resident's diabetes was poorly controlled. The resident was started on Lantus (glargine, long acting insulin) 10 units twice daily, in addition to Humalog (lispro, short-acting insulin) per sliding scale coverage, plus Humalog 3 units with meals. Chemstrips (fingerstick glucose readings) were improving. The 1/11/2023 at 10:59 AM Hospital discharge summary physician orders documented: - insulin glargine (a long-acting insulin) 100 units per milliliter injection, inject 10 units under the skin in the morning and 10 units before bedtime. - insulin lispro (a short-acting insulin) 100 units per milliliter injection, inject 5 units in the morning, 5 units at noon and 5 units in the evening. Inject with meals. - insulin lispro 100 units per milliliter injection, inject 0-14 units (sliding scale) under the skin four times a day before meals and nightly. - stop taking glimepiride (an oral anti-diabetic medication) 4 milligrams. The facility admission physician orders documented: - on 1/11/2023 (untimed) insulin glargine (Lantus, a long-acting insulin) solution 100 units per milliliter, inject 10 units subcutaneously (under the skin) twice a day for diabetes. - on 1/11/2023 at 5:09 PM (telephone order) documented accuchecks (finger sticks) before and after meals and at bedtime for diabetes. Call medical if less than 70 milligrams/deciliter and greater than 450 milligrams/deciliter. The order was entered into the computer at 5:11 PM by Registered Nurse #22 with the order type documented as standard other. The order was signed by Nurse Practitioner #15 on 1/13/2023 at 5:46 PM. There was no documented evidence of a facility admission physician order for routine short acting insulin and sliding scale insulin per the hospital discharge orders. The Weight and Vital Signs Summary did not include blood sugar (accuchecks) results prior to 1/21/2023. The 1/12/2023 Nurse Practitioner #15 progress note documented they reviewed external medical records. Hospital labs and consults were reviewed. The plan was to continue with Lantus 10 units twice daily and follow accuchecks (blood glucose finger sticks). There was no documented evidence Nurse Practitioner #15 reviewed accuchecks or the hospital discharge summary which included routine short acting insulin and sliding insulin scale. The 1/16/2023 Physician #14 History and Physical documented hospital labs and consults were noted and reviewed. The resident had controlled type 2 diabetes. The plan was to continue with Lantus 10 units twice daily and follow. There was no documented evidence Physician #14 reviewed accuchecks or the hospital discharge summary which included routine short-acting insulin and sliding insulin scale. The 1/21/2023 at 1:38 PM nursing progress note by Licensed Practical Nurse #23, documented the resident had a heart rate of 124 beats per minute. Physician #31 was updated on the resident's status and ordered the resident be sent to the emergency room for evaluation. An ambulance was called, and a message was left for the family representative. Licensed Practical Nurse #23 documented at 1:53 PM, the resident was admitted to the hospital for hyperkalemia (high blood potassium levels). The 1/21/2023 at 6:42 PM hospital physician progress note documented Resident #1 presented to the emergency room with an increased heart rate and mental status changes. They were found to have an elevated blood sugar level of 1192 milligrams/deciliter (drawn at 2:45 PM, normal for non-diabetic 75-115) and an elevated potassium level (7.0 milliequivalents/liter, normal 3.5-5.2). The resident was administered an insulin drip via intravenous (by vein) route and was started on medication to reduce their elevated potassium levels. Physician #29 documented the resident would be admitted into the Intensive Care Unit. Repeat blood work showed the resident continued with elevated blood sugar levels. The 1/25/2023 at 2:47 PM facility Physician #14 progress note documented Resident #1 was seen for a history and physical on 1/16/2023, medications and medication administration records were reviewed, and plan was to continue insulin glargine 10 units twice a day for type 2 diabetes. The progress note did not identify the instructions from the 1/11/2023 hospital discharge summary or identify Resident #1 had no accuchecks or short-acting insulin since admission. The 1/26/2023 at 10:37 AM hospital discharge summary documented the resident's discharge diagnosis was hyperosmolar hyperglycemic state (severely high blood glucose levels and other high level of substances in the blood). The resident had poorly controlled diabetes with a Hemoglobin A1C of 10.7% (a blood test that measures average blood glucose levels over the past 2-3 months, normal is less than 5.7%). The plan was to follow up with endocrinology as an outpatient. During an interview on 2/19/2025 at 10:49 AM with Nurse Practitioner #15, they stated hospital discharge orders were initially reviewed by staff who approved the admission and then forwarded to nursing. Nursing reviewed the orders, and verbal orders were given by the providers until they could see the resident, typically within 48-72 hours of their arrival. Nursing would initially review orders and call with any discrepancies, and they would review orders and labs when they arrived. They were not aware if Resident #1 had orders for short-acting insulin as it was two years ago. They stated hospitals often prescribed short-acting insulin for diabetics but became problematic if the resident did not eat. Nurse Practitioner #15 stated they would have kept the order for short-acting insulin for Resident #1 due to their history of uncontrolled diabetes and their A1C lab value (a lab value that measures blood glucose levels over time) of 10.7%. This clearly showed Resident #1's diabetes was not under control and they needed close monitoring. Anytime a resident with diabetes had complications including hospitalization, they always required glucose monitoring to determine how stable their blood glucose levels were. It was important to monitor Resident #1's blood glucose levels and administer appropriate insulin. They stated progress notes written by them were signed within two (2) days and reflected the resident's current plan of care. During an interview on 2/20/2025 at 9:18 AM, Physician #14 stated they had been the Medical Director of the facility for the past two years. They oversaw all residents in the facility. They stated hospital discharge/admission orders were first reviewed by nursing and then the nurse practitioners. They would not see newly admitted residents for a week. They stated they reviewed records the best they could but had to check records on three different computer systems that were not connected to one another. Residents with diabetes should have their blood glucose monitored and receive short or long-acting insulin if ordered. They could not recall Resident #1 or if they had active blood glucose or insulin orders. They stated hyperosmolar hyperactive state was a complication of diabetes and could happen if a resident's blood sugars were not monitored or insulin was not administered. Progress notes written by them were not signed or dated on the same day, but within two (2) days and reflected the Resident's current plan of care. 10NYCRR 415.15(b)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (NY00309249), the facility failed to ensure residents were free of significant medication errors for one (1) of four (4) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge orders included routine short acting insulin and sliding scale (the amount of insulin administered is based on the results of blood glucose finger sticks) short acting insulin. The resident's admission physician orders included long-acting insulin and blood glucose monitoring before and after meals, and at bedtime. The physician orders were not transcribed to the Medication Administration Record and the resident did not have blood glucose level readings completed for 10 days. Additionally, the resident did not have admission orders for routine short acting insulin and sliding scale short acting insulin as recommended. Subsequently, Resident #1 was hospitalized for hyperosmolar hyperglycemic state (severely high blood glucose levels with severe dehydration and confusion). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The facility policy, Medication Requisition Worksheet, revised 2/2015, documented medication reconciliation occurred at the time of admission and within 24 hours for each new resident admitted to the facility. The first reconciliation occurred by the pharmacist upon submission of the physician orders. The second reconciliation was completed when nursing reviewed all the medications listed on the hospital discharge summary/transfer sheet by way of a medication reconciliation worksheet. Nursing would complete the medication reconciliation worksheet before notifying the physician for initial verification of orders. Nursing would carefully review medications recommended by the hospital at discharge and list medications that needed clarification. Nursing would notify the physician of any discrepancies. The servicing pharmacy would conduct their own internal reconciliation upon receipt of orders and communicate any discrepancies to the ordering physician or nursing supervisor for clarification. The facility policy, Diabetes Management Protocol, issued 6/2014 and 3/2023, documented for insulin dependent diabetic residents, the responsible nurse administered routine insulin as ordered, performed finger sticks as ordered, administered short acting insulin per sliding scale, monitored residents for symptoms of hypoglycemia/hyperglycemia (low or high blood sugar levels in the blood), documented finger stick results, dose of insulin, where administered, and re-evaluated requirements of sliding scale insulin periodically to optimized routine orders. Resident #1 had diagnoses including Type 2 diabetes (the body does not use insulin effectively or does not produce enough insulin) and multiple sclerosis (a central nervous system disease). There was no admission Minimum Data Set assessment yet completed prior to the resident's discharge to the hospital on 1/21/2023. The hospital physician Discharge summary dated [DATE] at 2:42 PM documented the resident's diabetes was poorly controlled. The resident was started on Lantus (glargine, long acting insulin) 10 units twice daily, in addition to Humalog (lispro, short acting insulin) per sliding scale coverage, plus Humalog 3 units with meals. Chemstrips (fingerstick glucose readings) were improving. The 1/11/2023 at 10:59 AM hospital discharge orders documented: - Insulin glargine 100 units per milliliter injection, inject 10 units under the skin in the morning and 10 units before bedtime. - insulin lispro 100 units per milliliter injection, inject 5 units in the morning, 5 units at noon, and 5 units in the evening. Inject with meals. - insulin lispro 100 units per milliliter injection, inject 0-14 units (sliding scale,) under the skin 4 (four) times a day before meals and nightly. - stop taking glimepiride (an oral anti-diabetic medication) 4 milligrams. The facility admission physician orders documented: - on 1/11/2023 (untimed) insulin glargine solution 100 units per milliliter, inject 10 units subcutaneously (under the skin) twice a day for diabetes. - on 1/11/2023 at 5:09 PM (telephone order) accuchecks (blood glucose finger sticks) before and after meals and at bedtime for diabetes. Call medical if less than 70 milligrams/deciliter and greater than 450 milligrams/deciliter. The order was entered into the computer at 5:11 PM by Registered Nurse #22 with the order type documented as standard other. The order was signed by Nurse Practitioner #15 on 1/13/2023 at 5:46 PM. There was no documented evidence of an admission physician order for routine short acting insulin and sliding scale insulin. The Comprehensive Care Plan initiated 1/11/2023, documented the resident had diabetes mellitus. Interventions included diabetes medications as ordered, monitor/document for side effects/effectiveness, dietary consult for nutritional regimen and ongoing monitoring, finger stick blood sugars as ordered by physician, monitor/document/report as needed signs/symptoms of hyperglycemia (high blood sugar), including increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps and pain, Kussmaul's breathing (rapid breathing), acetone (fruity) breath, coma. The 1/2023 Medication Administration Record documented insulin glargine inject 10 units subcutaneously two (2) times per day for diabetes with a start date of 1/11/2023. There was no documented evidence of orders or results for accuchecks from 1/11/2023-1/21/2023. The Weight and Vital Signs Summary did not include blood sugar (accuchecks) results prior to 1/21/2023. The 1/12/2023 Nurse Practitioner #15 progress note documented they reviewed external medical records. Hospital labs and consults were reviewed. The plan was to continue with Lantus 10 units twice daily and follow accuchecks (blood glucose finger sticks). There was no documented evidence Nurse Practitioner #15 reviewed accuchecks or the hospital discharge summary which included routine short acting insulin and sliding scale insulin. The 1/16/2023 Physician #14 History and Physical documented hospital labs and consults were noted and reviewed. The resident had controlled type 2 diabetes. The plan was to continue with Lantus 10 units twice daily and follow. There was no documented evidence Physician #14 reviewed accuchecks or the hospital discharge summary which included routine short acting insulin and sliding scale insulin. The 1/19/2023 at 8:26 PM progress note by Licensed Practical Nurse #33 documented the resident was alert and oriented and able to make needs known. No complaints of pain or discomfort voiced. Licensed Practical Nurse #23 progress notes documented: - on 1/21/2023 at 11:53 AM the resident followed verbal directions but did not respond verbally. The resident had an elevated heart rate of 128 beats per minute (normal 60-100 beats per minute), and neurological checks were within normal limits. The resident had no signs of distress. Director of Nursing #20 and on-call Physician #31 were notified. There was no documented evidence the resident's blood glucose level was checked. - on 1/21/2023 at 12:38 PM Physician #31 ordered labs including a complete blood count, comprehensive metabolic panel, ammonia level, and a urinalysis with culture and sensitivity (determines possible presence of a urinary tract infection). Continue neurological checks and monitor the resident's vital signs in 1-2 hours. If the resident's heart rate did not come down, the provider would order medication. The resident responded verbally and denied pain or discomfort. The resident's heart rate was 122 beats per minute. - on 1/21/2023 at 1:38 PM the resident had a heart rate of 124 beats per minute. Physician #31 was updated and ordered the resident be sent to the emergency room for evaluation. An ambulance was called, and a message was left for the family representative. - on 1/21/2023 at 1:53 PM the resident was admitted to the hospital for hyperkalemia (high blood potassium levels). The Weights and Vital Signs Report documented on 1/21/2023 the resident's blood glucose results were 118 milligrams/deciliter at 11:33 AM and 118 milligrams/deciliter at 11:34 AM. The 1/21/2023 at 6:42 PM hospital physician progress note documented Resident #1 presented to the emergency room with an increased heart rate and mental status changes. The resident had an elevated blood sugar level of 1192 milligrams/deciliter (drawn at 2:45 PM, normal for non-diabetics 75-115 milligrams per deciliter) and an elevated potassium level (7.0 milliequivalents/liter, normal 3.5-5.2 milliequivalents/liter). The resident was administered an insulin drip via intravenous (into a vein) route and was started on medication to reduce their elevated potassium levels. The resident would be admitted into the Intensive Care Unit. Repeat blood work showed the resident continued with elevated blood sugar levels. The 1/26/2025 at 10:37 AM hospital discharge summary documented the resident's discharge diagnosis was hyperosmolar hyperglycemic state. The resident had poorly controlled diabetes with a Hemoglobin A1C of 10.7% (a blood test that measures average blood glucose levels over the past 2-3 months, normal is less than 5.7%). The plan was to follow up with endocrinology as an outpatient. The 1/24/2023 at 9:55 AM Facility accident/incident investigation summary completed by the Administrator documented: - On 1//11/2023 Resident #1 was admitted to the facility and their physician orders for blood glucose monitoring did not transcribe to the Medication Administration Record. The order was inputted as a standard order instead of a MAR order. - On 1/21/2023 at 1:55 PM, Resident #1 had increased pulse, lethargy (tiredness), and confusion and was sent to the hospital and was found to have hyperglycemia. - On 1/23/2023 at 8:00 AM, the hospital updated the Administrator. Resident #1 was admitted with a high blood glucose level, hyperkalemia, and hypernatremia (high blood sodium levels). The resident's blood glucose level was 1192. The Health Care Proxy was at bedside and stated they did not believe the resident had received blood glucose finger sticks or insulin since their admission to the facility. - On 1/23/2023 at 8:30 AM, the facility became aware Resident #1 had a blood glucose level of 1192. The resident's blood glucose prior to transfer was 118. The facility verified a care plan violation had occurred, and the resident's blood glucose monitoring did not transcribe and reflect on the medication or treatment administration records. The allegedly responsible employee (unidentified) was issued a disciplinary notice and re-educated on transcription of orders and secondary verification by a second nurse. During an interview on 1/27/2025 at 1:39 PM, Licensed Practical Nurse #2 stated registered nurses, and licensed practical nurses were responsible for entering provider orders into the computer system once the provider had issued an order. Nursing input the order and scheduled the time of administration based on the physician order. An order for a blood glucose (sugar) fingerstick would be entered into the computer to be done before and after meals, did not require a specific time, and nursing was trained to know what before and after meals indicated. Nursing had one hour before or after the scheduled time to administer medications. Licensed Practical Nurse #2 was unsure if additional boxes needed to be checked when the order was entered into the computer. During an interview on 1/28/2025 at 11:58 AM, Licensed Practical Nurse # 26 stated physician orders were entered into the computer. If an order for a blood glucose fingerstick was before and after meals and at bedtime, it was entered as a new order. They ensured the category standard medication-electronic medical record box was checked. This allowed nursing to see the order on the resident's electronic medication administration record. If the correct box was not checked, the physician order would only show up under general physician orders in the medical chart and would not transfer to the medication administration records and the fingerstick would be missed. The Director of Nursing was interviewed: - on 1/31/2025 at 1:50 PM, they stated orders were issued on paper by the nurse practitioner or physician and licensed nurses were responsible for putting the orders into the computer. A blood glucose monitoring fingerstick order would need to be placed under the category standard-electronic medical record, or electronic medication administration record order, for it to show on the medication administration record. - on 2/3/2025 at 8:23 AM, they stated they or the Assistant Director of Nursing reviewed hospital discharge orders. The current second check system occurred when they entered orders, and a second person checked them. They did not check their own entries. Another second check occurred the next day by the nurse practitioner. Once orders were entered, the after-visit summary which included the resident's discharge medications, would be scanned into the resident's electronic medical record under the miscellaneous tab. This was completed by 5:00 PM each day. It was rare that a nursing supervisor or off-shift nurse entered orders. If they did, the Director of Nursing or Assistant Director of Nursing would do the second check the following day. The only way to know if an order was transcribed incorrectly would be during a second check the following day. It was important for residents with diabetes to have their orders transcribed appropriately and receive their accuchecks and insulin or it could pose a serious health risk to the resident. It was considered a medication error if the orders were not transcribed correctly. During an interview on 2/6/2025 at 9:47 AM, Licensed Practical Nurse #28 stated Resident #1 was a bad diabetic. They stated they did not recall monitoring the resident's blood sugars from admission. Their nursing judgement would be to check the resident's blood glucose level before they administered insulin and call the physician for an order. Resident #1's blood sugars could have been low if they received insulin without their blood sugar being monitored. Licensed Practical Nurse #28 stated if Resident #1's physician order for finger sticks did not show up on the medication records then whomever placed the order made an error. The medication administration record would issue a reminder at least ½ half an hour before the fingerstick was due. Nurse Practitioner #15 was interviewed: - on 2/6/2025 at 10:17 AM, they stated all newly admitted diabetic residents received orders to monitor their blood sugars. Blood sugars (finger sticks) were monitored for at least five (5) days to evaluate whether the resident was stable and needed higher or lower doses of insulin or less frequent blood sugar monitoring. They expected nursing to enter the orders and check them for accuracy and review the resident's results with the provider after 5 days. Nurse Practitioner #15 stated they were Resident #1's primary care provider before admission, and the resident had uncontrolled diabetes for many years. They should have had blood glucose monitoring every day per their order. They were not aware the resident's finger sticks were not being obtained and did not know Resident #1 was hospitalized for a blood sugar of 1192. They stated the resident's emergency room diagnosis was a direct result of their finger sticks not being obtained. Hyperosmolar hyperglycemic state was a life-threatening condition caused from prolonged high blood sugars. Resident #1 not having their blood sugar monitored could have led to their death if they were not hospitalized . - on 2/19/2025 at 10:49 AM, they stated hospital discharge orders were initially reviewed by staff who approved the admission and then forwarded to nursing. Nursing reviewed the orders, and verbal orders were given by the providers until they could see the resident, typically within 48-72 hours of their arrival. Nursing would initially review orders and call with any discrepancies, and they would review orders and labs when they arrived. They were not aware if Resident #1 had orders for short-acting insulin as it was two years ago. They stated hospitals often prescribed short-acting insulin for diabetics but that became problematic if the resident did not eat. Nurse Practitioner #15 stated they would have kept the order for short-acting insulin for Resident #1 due to their history of uncontrolled diabetes and their lab value A1C level of 10.7%. This clearly showed Resident #1's diabetes was not under control and needed close monitoring. It was important to monitor Resident #1's blood glucose levels and administer insulin. If blood glucose levels were too high, kidney disease, ketoacidosis, cardiac or vascular disorders such as stroke could occur. - on 2/20/2025 at 9:48 AM, they stated Resident #1's blood glucose level of 118 decimeters per milliliter prior to their emergency room transfer could have been altered if nursing did not wait for alcohol to dry on their finger before obtaining the fingerstick reading. A blood glucose level of 1192 decimeters per milliliter could only result from a lab draw because glucometers did not read above 600. The facility glucometers were checked monthly for calibration and controls. During an interview on 2/7/2025 at 12:39 PM, Registered Nurse #20 stated licensed nurses were trained during orientation on how to put physician orders into the computer. They had an extra day during training to learn the various types of orders. The facility had a two-person check system. When a new physician order was entered into the computer it would go into a queue and a second nurse would sign into the computer to verify the order. The second nurse's username and password would time stamp and sign their name and that indicated the order had been checked. During an interview on 2/20/2025 at 9:18 AM, Medical Director #14 stated hospital discharge/admission orders were first reviewed by nursing and then the nurse practitioners. They saw newly admitted residents in the first week. They reviewed records the best they could but had to check records on three different computer systems that were not connected to one another. Residents with diabetes should be monitored for their blood sugars and receive short or long-acting insulin if ordered. They could not recall Resident #1 or if they had active blood glucose or insulin orders. They stated hyperosmolar hyperactive state was a complication of diabetes and could happen if a resident's blood sugars were not being monitored or insulin was not administered. 10NYCRR 415.12 (m)(2)