**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for six of 22 residents (R2, R11, R58, R73, R86, and R94). Findings Include: Review of facility policy Diabetic Protocol dated 6/1/25, previously dated 1/1/25, 1/1/24, indicated provider and staff will work together to give appropriate treatment to manage diabetes. The provider will follow up on any acute episodes associated with significant blood glucose level changes and deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. The staff will identify and report complications such as hypoglycemia. Review of the facility Hypoglycemia Policy dated 6/1/25, previously dated 1/1/25, 1/1/24, indicated nursing personnel are responsible for recognizing signs and symptoms of hypoglycemia and responding accordingly. When acute hypoglycemia is suspected, assess mental status (alert, drowsy, uncooperative, or unconscious) and use glucometer to determine the resident's blood sugar level. A blood glucose of 70 mg/dL or less may indicate the need for intervention. If there are no provider orders for specific treatment do the following: -If the resident is conscious and treatment is indicated, give 1 tube of dextrose gel (15 grams). -After 15 minutes, repeat blood sugar and if still under 70 mg/dL, repeat glucose gel. -After 15 minutes repeat blood sugar. If above 70 mg/dL, give a snack of protein and a carbohydrate (ex. ½ sandwich with bread and a protein or crackers and a protein.) Monitor until stable. -If the resident is drowsy or unconscious or is unable or unwilling to consume anything orally, administer glucagon 1 mg subcutaneously. Monitor the resident for 15 minutes after treatment. -If, after 15 minutes, the resident is conscious and able to consume orally, give a snack of a protein and a carbohydrate (ex. ½ a sandwich with bread and a protein or crackers and a protein). Monitor until stable; -If, after 15 minutes the resident still cannot consume anything orally, repeat glucagon 1 mg subcutaneously and call 911. Further review of the policy failed to reveal procedures in the event of a resident experiencing hyperglycemia. Review of the Facility assessment dated [DATE], indicated the facility will provide care for residents diagnosed with diabetes. Review of the United States Food and Drug Administration prescribing information for basaglar insulin (insulin glargine, a long-acting injectable medication to diabetes) dated 12/2015, indicated basaglar insulin begins to work several hours after administration, the maximum effect of basaglar insulin is approximately 12 hours after administration, and works over 24 hours to lower blood sugar levels. Review of the glucometer manufacturer's instructions indicated Low refers to less than 20 mg/dl, and High refers to greater than 600 mg/dl. Review of the clinical record indicated that Resident R73 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/30/25, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of a physician order for Blood glucose parameters dated 4/17/25, indicated If resident blood glucose 70< initiate Hypoglycemic protocol and Notify MD (Doctor of Medicine). If resident blood glucose 400> Notify MD. Review of Resident R73's plan of care for diabetes dated 4/14/25, indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R73's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up.: 5/29: 539 5/28: 409 5/24: 411 5/21: 453 5/14: 462, notified 8 hours later 5/13: 540 5/11: 565 5/11: 445 5/08: 489 4/30: 412 4/29: 425 4/03: 517 Review of the physician's order dated 6/6/24, indicated to provide insulin lispro on a sliding scale before meals and at bedtime. Review of Resident R73's meal consumption record on 8/25/24, indicated Resident R73 had consumed 50-75% of her lunch. Consumption was documented at 11:01 a.m. Review of Resident R73's blood sugar record indicated a blood sugar assessment on 8/25/24, at 11:55 a.m. of 371. Review of Resident R73's medication administration record for August 2024, indicated Resident R73 received 10 units of insulin lispro, the appropriate amount for a blood sugar of 371, if the blood sugar was assessed prior to eating. Review of a progress note dated 8/25/24, at 3:22 p.m. indicated Resident R73 was not responding to voice, was cold and clammy, and had a decreased level of consciousness. Resident R73's blood sugar was assessed at this time, noted to be 31. Resident R73 was transferred to the hospital by emergency services. Review of a progress note dated 8/25/24, at 10:14 p.m. indicated Resident R73 was admitted to the hospital for hypoglycemia. Review of hospital discharge paperwork dated 8/31/24, indicated, [Resident R73] was found by staff at [facility] with a sugar of 20. Review of a progress note dated 10/6/24, at 4:10 p.m. indicated that Resident R73 had fallen in her room. A blood sugar value was not documented in the note. Review of a progress note dated 10/6/24, at 5:38 p.m. indicated that Resident R73 had fallen in the hall. Resident was walking on the unit and fell. No injuries noted. While taking her vitals, staff noted that her CBG was 523. Resident has a fx (fracture) to R (right) shoulder from a fall about a month ago which is not completely healed. Son requested that she be sent to [hospital] to have her R shoulder evaluated and elevated blood sugar. MD notified. 911 called for transport. Review of hospital discharge paperwork dated 10/6/24, indicated Resident R73's reason for the emergency room visit was a fall, with the diagnosis of hyperglycemia. Review of the clinical record indicated that Resident R11 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes and chronic kidney disease (gradual loss of kidney function). Review of physician orders dated 5/25/24, indicated Resident R11 received rapid acting insulin: with breakfast (7:00 a.m. - 10:00 a.m.), with lunch (11:00 a.m. - 12:00 p.m.), and with afternoon med pass (4:00 p.m. - 6:00 p.m.), If CBG <60 give 0 units. 60-100 give 8 units. If CBG >100, give 16 units. Review of Resident R11's plan of care for diabetes initiated 7/26/23, indicated for staff to Monitor for signs of hyperglycemia (blood glucose > 140mg/dl) and administer medications per physician's orders. Review of Resident R11's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/27: 480 6/24: 403 6/17: 533 6/17: 421 6/07: 421 6/07: 508 5/27: 490 5/24: 501 5/24: 430 5/22: 356 5/12: 360 5/11: 400 5/06: 388 5/05: 360 5/04: 369 5/08: 489 4/27: 357 4/18: High 4/15: 424 Review of Resident R11's blood sugar level on 5/29/25 indicated that at 8:26 p.m. Resident R11's blood sugar level was 515, and at 11:19 p.m. was 444. Review of a progress note written by Registered Nurse Supervisor Employee E9 dated 5/29/25, at 11:47 p.m. indicated, Call placed to on call provider for [doctor] in reference to resident blood glucose reading of 515, received 33u (units) of basaglar insulin, recheck performed and blood glucose 444. Spoke with on call physician, given order to transfer resident to ER for evaluation due to elevated blood glucose levels. Review of hospital discharge paperwork dated 5/30/25, indicated Resident R11 was seen in the emergency room for hyperglycemia and a urinary tract infection. Review of the physician notification sheet dated 5/29/25, indicated for Resident R11, Returning, had elevated (upward pointed arrow) BGM. During an interview on 7/2/25, at approximately 2:00 p.m. the Director of Nursing confirmed that basaglar insulin would not have an appreciable effect on Resident R11's elevated blood sugar level. Review of the clinical record indicated that Resident R2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness). Review of a physician order dated 4/2/25, indicated for Resident R2 to sliding scale insulin coverage with meals, and to notify the MD if Resident R2's CBG is less than 60 or greater than 340. Review of Resident R2's plan of care dated 6/13/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R2's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/24: 460 6/24: 387 6/24: 389 6/21: 451 6/20: 394 6/18: 346 6/13: 414 6/03: 401 6/03: 435 5/28: 413 5/28: 477 4/23: 395 4/08: 402 4/08: 516 Review of the clinical record indicated that Resident R58 was admitted to the facility on [DATE]. Review of the MDS for Resident R58 dated 6/4/25, included diagnoses of diabetes, acquired absence of right leg below knee (amputation below right knee), unspecified intracranial injury without loss of consciousness (injury to the brain without loss of consciousness, might experience confusion, headache or amnesia). Review of a physician order dated 6/18/25, indicated for Resident R58 a sliding scale insulin coverage with meals, and to notify the MD if Resident R58's CBG is less than 60 or greater than 341. Review of Resident R58's plan of care dated 5/6/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R58's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/29: 371 6/27: 368 6/10: 394 6/04: 434 5/29: 406 5/27: 390 5/24: 395 5/23: 381 5/19: 359 4/29: 401 4/23: 355 4/22: 358 4/20: 373 4/09: 378 4/07: 386 4/01: 350 Review of the clinical record indicated that Resident R86 was admitted to the facility on [DATE]. Review of the MDS for Resident R86 dated 6/3/25, included diagnoses of diabetes, high blood pressure, osteomyelitis of vertebrae, thoracic region (bone infection in the middle back). Review of a physician order dated 4/17/25, indicated for Resident R86 a sliding scale insulin coverage with meals, and to notify the MD if Resident R86's CBG is less than 60 or greater than 340. Review of Resident R86's plan of care dated 5/8/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R86's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/10: 350 6/04: 351 5/04: 350 5/03: 396 4/19: 403 4/19: 366 4/19: 371 4/17: 388 4/11: 345 4/05: 371 Review of the clinical record indicated that Resident R94 was admitted to the facility on [DATE]. Review of the MDS for Resident R94 dated 6/3/25, included diagnoses of diabetes, history of falling, fracture of left femur (a break in the long bone in upper leg). Review of a physician order dated 4/17/25, indicated for Resident R94 a sliding scale insulin coverage with meals, and to notify the MD if Resident R94's CBG is less than 70 or greater than 350. Review of Resident R94's plan of care dated 5/15/25, for diabetes indicated Labs as ordered by doctor. Contact md with any abnormalities. Follow facility routines for hypo/hyperglycemic episodes. Review of Resident R94's blood sugar record for April 2025, through June 2025, revealed the following blood sugar values failed to have documentation of notification or follow-up: 6/20: 360 6/10: LOW (no repeat conducted) 6/07: 419 5/10: LOW (no repeat conducted) 4/18: 417 4/18: 403 The Nursing Home Administrator (NHA) and the DON were made aware that an Immediate Jeopardy situation existed for residents on 7/1/25, at 12:50 p.m. and a corrective action plan was requested. The Immediate Jeopardy template was provided to the facility administration at this time. On 7/1/25, at 2:30 p.m. an acceptable Corrective Action Plan was received which included the following interventions: After record review, it was determined that [the facility] failed to notify the physician of blood sugars out of range timely for six residents and care plans were absent or did not include approaches for diabetic emergency management. Immediate Actions: -Resident R73, R11, R2, R94, R86, R58 was assessed by the Director of Nursing on 07/01/2025 at 1325. Residents R73, R11, R2, R94, R86, and R58 had no s/s hyperglycemia at that time. -Education was initiated on 07/01/2025 with facility RN's and LPN's on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition, and notifications to the physician of blood sugars out of range. The facility is currently not using any agency staff. Moving forward, if any agency RN or LPN need to be utilized, they will be educated on the diabetic protocol before their first day of work. -On 07/01/2025, Residents R73, R11, R2, R86, R58's blood sugars were reviewed from the past 24 hours to ensure none were out of range without physician notification. -On 07/01/2025, an ad hoc QAPI committee meeting was held, and the medical director was made aware of the findings. Like Residents: -Current residents with diabetes have the potential to be affected. Current residents with diabetes were reviewed on 07/01/2025 by the DON to determine if blood sugars were out of range and none were noted out of range. Correction of System: -Root cause analysis completed by the center QAPI committee on 07/01/2025 and determined failure to follow the Resident Change in Condition policy led to the allegation. -To prevent recurrence, the Director of Nursing initiated education with facility RN's and LPN's on 07/01/2025 on the Diabetic Protocol, the Hypoglycemia policy, and the Resident Change in Condition policy to include hyperglycemia is a change in condition and notification of the physician of blood sugars out of range. RN's and LPN's that were not on duty received education via phone and will receive in person education on their next scheduled shift. -Moving forward any new RN's and LPN's hired will be educated on the Resident Change of Condition policy, the Diabetic Protocol, and the Hypoglycemia policy in orientation by the Director of Nursing/ designee. Monitoring: -To monitor and maintain compliance, the Director of Nursing/ designee will review blood sugars daily x 2 weeks, 3x a week x 2 week and then weekly x 2 weeks to determine if any blood sugars were out of range and notifications made. If notification not documented, the physician will be contacted at the time of discovery and notified and new orders implemented as needed. -To monitor and maintain compliance, new admissions/ readmissions with diabetes will be reviewed by the DON/ designee to ensure a care plan is implemented for diabetes including approaches for diabetic emergency management 5 x a week for 2 weeks, then weekly x 3 weeks. -Results of the audits will be forwarded to the center QAPI committee for review and recommendations. On 7/2/25, care plans for affected residents were reviewed, and confirmed they were corrected to show goals and interventions related to diabetes and blood glucose monitoring. On 7/2/25, the whole house audit was reviewed by surveyors, revealing its completion and accuracy. During interviews beginning at approximately 8:30 a.m. on 7/2/25, four of four LPNs on duty were able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. During interviews beginning at approximately 1:30 p.m. on 7/2/25, one of one RN on duty was able to describe the correct procedure for documenting, monitoring, and needs of notification for blood sugars outside of the ordered parameters. The Immediate Jeopardy was removed on 7/2/25, at 11:08 p.m. when the action plan implementation was verified. During an interview on 7/3/25, at approximately 3:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for six of 22 residents. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.