**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of hospital, and clinical records, and interviews with staff, it was determined that the facility failed to properly assess, monitor, and provide treatment for a resident with known condition of diabetes resulting in the harm of hospitalization after experiencing hypoglycemia (low sugar in blood) for one of three residents reviewed (Resident CL1). Findings include: Review of Resident CL1's clinical record revealed Resident CL1 was admitted to the facility on [DATE]. Review of Resident CL1's diagnosis list includes Diabetes Mellitus (group of metabolic disorders characterized by a high blood sugar level over a prolonged period) long-term (current use of insulin), and Chronic Kidney Disease. Review of Resident CL1's hospital records including document labeled Clinical Summary created on September 22, 2024, revealed the resident was on blood sugar monitoring three times daily. The same document indicated, regarding Resident CL1's DM (Diabetes Mellitus), with the use of insulin, the plan was to continue to monitor POTC (point-of-care test) Accuchecks (machine used to check blood glucose); Hypoglycemia and Hyperglycemia (high blood sugar) protocol in place; and encourage p.o. (by mouth) intake. Review of Resident CL1's hospital record Emergency Department Provider Notes dated September 21-22, 2024, revealed the resident's POTC glucose was checked. A laboratory report dated September 21, 2024, showed a Glucose level of 166 mg/dl (Normal range 80-130 mg/dl). Review of Resident CL1's physician orders dated September 22, 2024, revealed the following orders: Insulin Aspart Protamine & Aspart Suspension (Aspart 70/30- premixed insulin that starts to work within 10 to 20 minutes after injection, peaks in 2 hours, and keeps working for up to 24 hours) Inject 25 units two times daily.; Insulin Aspart Solution (fast-acting insulin) Inject 16 units one time a day (Scheduled at noon); Insta-Glucose Gel 77.4% Give one dose by mouth as needed for blood glucose less than 70, for a patient who is arousable conscious, and able to swallow if repeat blood glucose is below 70 mg/dl. Continue to hold all diabetic medications until the provider authorizes resumption; Glucagon Emergency Kit 1 mg Inject 1 mg intramuscularly as needed for blood glucose less than 70, not arousable conscious or able to swallow if repeat blood glucose is below 70 mg/dl and the patient is not arousable, conscious, or able to swallow. Continue to hold all diabetic medications until the provider authorizes resumption, and the Hypoglycemia protocol observes signs/symptoms of Hypoglycemia as needed if blood glucose is less than 70 mg/dl or ordered low parameters follow the Hypoglycemia protocol. Review of Resident CL1's clinical record failed to reveal a blood glucose monitoring order despite the notation within hospital record of insulin administration and Hypoglycemia protocol orders. Interview with the Director of Nursing (DON) was conducted on October 7, 2024. The DON agreed no blood glucose order was done since it was not indicated on the resident's hospital discharge summary/instructions. Review of Resident CL1's clinical record failed to reveal facility staff clarified the admission orders to the physician, regarding how to monitor for hypoglycemia and how to implement hypoglycemia protocol without monitoring Resident CL1's blood glucose level. Review of Resident CL1's September 2024, Medication Administration Record (MAR) revealed the resident was administered Insulin Aspart 70/30, 20 units on September 23, 2024, at 8:00 a.m., and Insulin Aspart 16 units at noon. Review of Resident CL1's vitals revealed Resident CL1's blood glucose was checked on September 23, 2024, at 7:30 a.m., with a result of 187 mg/dl, and September 23, 2024, at 11:30 a.m., with a result of 100 mg/dl. Interview with the Director of Nursing on September 23, 2024, revealed the nurse checked Resident CL1's blood glucose before the above insulin administration as a nursing judgment. Review of Resident CL1's physician's progress notes dated September 23, 2024, at 1:11 p.m., revealed under assessment a Plan for DM, continue insulin, and monitor blood sugar. Review of Resident CL1's clinical record failed to reveal an order for blood sugar monitoring. Review of Resident CL1's nursing progress notes dated September 23, 2024, at 10:46 p.m., revealed around 4:00 p.m., the resident complained of a headache, the charge nurse assessed the resident and was administered two tablets of Tylenol (medication to treat mild pain). Review of Resident CL1's clinical record failed to reveal the resident was thoroughly assessed after complaining of a headache. The resident's blood pressure and blood sugar were not assessed. A pulse rate (81 BPM) and respirations (18) were assessed on September 23, 2024, at 3:40 p.m. Review of Resident CL1's MAR revealed Resident CL1 was administered with Insulin Aspart 70/30 25 units on September 23, 2024, at 5:00 p.m. Review of Resident CL1's meal consumption revealed the following: September 23, 2024, at 8:00 a.m., (25% eaten); noon (50% eaten), and 8:23 p.m., (25% eaten). Review of Resident CL1's nursing progress notes dated September 23, 2024, at 10:46 p.m., revealed around 8:00 p.m., the resident's family came and observed the resident with eyes closed and not responding. The nursing supervisor was notified, 911 was called and the resident was sent to the emergency room. Review of Resident CL1's hospital transfer form dated September 23, 2024, revealed the reason for the transfer was altered mental status, vitals as follows: Blood pressure 146/57 mmHg; pulse 75 BPM; respirations 18/min.; temperature 97.7 F; and Spo2 was 91%. Records did not reveal blood sugar was checked. Review of Resident CL1's hospital records and emergency provider notes dated September 23, 2024, revealed patient presents to the ED (Emergency Department) for evaluation of altered mental status. On arrival, the patient is lethargic and unable to answer any questions. Per medics, blood sugar was 59. Additional hospital records review and ED clinical impression revealed initial fingerstick glucose performed on arrival showing blood sugar to be 30, Dextrose (medication used to treat low blood sugar) was given. The patient was also found to be with hypokalemia (low potassium level). The patient was admitted with Altered Mantal Status, Hypoglycemia, and Hypokalemia. Hospital blood work done on September 23, 2024, revealed a blood glucose level of 25 mg/dl. The above information was conveyed to the Director of Nursing on October 7, 2024, at 1:00 p.m. The facility failed to assess, monitor, and provide necessary treatment to Resident CL1's for Diabetes resulting in hospitalization for low blood sugar levels. 28 Pa. Code: 211.12(d)(5) Nursing Services Previously cited 7/1/24 28 Pa. Code: 211.12 (d)(1)(3) Nursing Services Previously cited 7/1/24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policy, hospital records and clinical records, and staff interviews, it was determined that the facility failed to follow a physician's order and appropriately monitor the resident's hematuria (blood in urine) and failed to timely notify the physician of resident's abnormal vitals resulting to the harm of being hospitalized for one of six residents reviewed (Resident CL1). Findings include: Review of the facility's policy titled Change in condition: Notification of, with a revision date of June 1, 2021, revealed A Center must immediately consult with the patient's physician where there is: A significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). Review of Resident CL1's Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated April 9, 2023, revealed resident was admitted to the facility on [DATE]. MDS revealed resident had moderate cognitive impairment and had an indwelling Foley catheter (A catheter that drains urine from your bladder into a bag outside your body). Review of Resident CL1's diagnosis list revealed, Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down), Congestive Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), Coronary Artery Disease, Urinary Retention, and Hematuria. Review of the admission physician's order dated April 4, 2023, revealed an order of Midodrine HCl Oral tablet given three tablets by mouth before meals for low blood pressure. Medication was scheduled to be given at 7:30 a.m., 11:30 a.m., and 4:30 p.m. Review of weights and vitals dated April 4, 2023, until April 8, 2023, revealed Resident CL1's blood pressure ranges from 142/81-111/71 mmHg (normal blood pressure = 90/60 to 120/80 mm Hg). Pulse rates range from 90-78 BPM (normal pulse = 60 to 100 BPM). Review of the Nurse Practitioner (NP) notes dated April 5, 2023, revealed Resident CL1's orthostatic hypotension was in clinically stable condition. Review of the nursing progress notes dated April 7, 2023, at 9:13 a.m., revealed resident had blood present on linens and hematuria noted in the foley bag, resident was assessed, resident reported going to the bathroom but was not aware of the catheter being tugged. NP (Nurse Practitioner) visited, ordered to flush the foley, unit manager to follow through with orders. Review of the physician notes dated April 7, 2023, revealed resident with urine retention with acute hematuria on April 7, 2023, maintain foley, flush and follow. Clinical records review failed to reveal the NP's verbal order to flush Resident CL1's Foley catheter was completed. Interview with the NP was conducted on May 1, 2023, at 1:00 p.m., and reported that nursing is responsible for placing verbal orders into the resident's EMR (Electronic Medical Record). Interview with the Director of Nursing (DON), on May 1, 2023, at 1:00 p.m., revealed both nursing and NP are responsible for placing the order into the resident's EMR. The DON confirmed that there was no documented evidence that Resident CL1's Foley was flushed. The clinical records review failed to reveal documentation/follow-up of Resident CL1's hematuria on April 8, 2023. A review of the nursing progress notes dated April 9, 2023, at 10:54 a.m., revealed blood pressure taken lying at 7:45 a.m., was 83/54 mmHg. The same note stated, Hematuria continues. Interview conducted with licensed nurse Employee E4 on May 1, 2023, at 12:30 p.m., confirmed resident had hematuria on April 9, 2023, and blood pressure taken at 7:54 a.m., was 83/54 mm Hg. Employee E4 reported the physician was not informed of the continued hematuria because it was not a new condition. Employee E4 reported that the blood pressure was not relayed to the physician because the resident had a diagnosis of orthostatic hypotension and Midodrine medication was administered with therapy session occurring after administration. Review of physical therapy notes dated April 9, 2023, revealed resident rolled to the right and left with minimal assistance, supine to sit on the edge of the bed, a resident reported lightheadedness and dizziness., blood pressure was 91/60 mm Hg, heart rate (HR) was 123 BPM. After five minutes of sitting resident with no symptoms reported, attempted to transfer from the bed to a wheelchair but the resident lost balance requiring moderate assistance to recover and sit on the edge of the bed, the blood pressure was 88/58 mm Hg, and HR was 120 . Sit supine with moderate assistance, blood pressure was 106/63 mm Hg, HR 127 BPM. Interview with Physical Therapy Assistant (PTA) Employee E5 was conducted on May 1, 2023, at 1:00 p.m. Employee E5 reported that the resident was seen before lunch on April 9, 2023, for a therapy session. Employee E5 reported that she/he was not notified of the Resident's earlier vitals (low blood pressure) but she/he always check the resident's vitals during therapy sessions. Employee E5 reported that the resident was unable to transfer from the bed to the wheelchair due to weakness and loss of balance, vitals were monitored during the session. Employee E5 reported that she/he discussed the resident's low blood pressure and resting elevated heart rate with the Physiatrist (doctor who has special training in physical medicine). Employee E5 also reported that the nurse on duty was notified of the abnormal vitals of the resident. Interview with Licensed nurse Employee E4 on May 1, 2023, at 1:00 p.m., revealed Employee E5 notified her/him of the resident's low blood pressure but was not made aware of an elevated heart rate. Employee E4 reported the physician was not notified of the low blood pressure during therapy because the therapist indicated the blood pressure returned to resident's baseline blood pressure. Employee E4 stated that for any significant change in a resident's condition, the primary physician, NP, or the on-call physicians need to be notified and not the rehab doctor. Employee E4 reported that the resident was last observed at 2:30 p.m. and reported the resident was ok. Review of the Physiatrist's notes on April 9, 2023, revealed HR of 90 BPM, respiration was 19, continue occupational therapy, physical therapy, medications, and medical management with [primary physician]. Review of the progress notes dated April 9, 2023, at 4:30 p.m., revealed resident was unresponsive, and would not follow simple commands, pulse oximeter noted 91% on room air, oxygen was administered, 911 was called, MD and family were notified, resident was sent to the hospital. Review of the vitals documented on April 9, 2023, at 5:00 p.m., revealed Resident CL1's blood pressure was 79/44 mm Hg, and HR was 131 BPM. Review of the progress notes dated April 10, 2023, at 10:26 a.m., revealed resident was admitted with a diagnosis of septic shock (A widespread infection causing organ failure and dangerously low blood pressure). Review of the hospital records Discharge summary dated [DATE], revealed resident's principal problem was septic shock. Presenting problem was Acute Kidney Injury, Urinary Tract Infection with hematuria, and Sepsis due to unspecified organism. The hospital course revealed the patient presented to the hospital on April 9, 2023, and was found to be lethargic, and hypotensive and required intubation after failing a BIPAP. The patient was admitted to the Intensive Care Unit for management of septic shock. The patient arrested and passed on April 11, 2023. Review of Resident 1's hospital record revealed under section titled HPI (History of Present Illness) that the resident had a recent hospital admission March 31 to April 4, 2023 for Orthostatic Hypotension. Further review of hospital record revealed, When EMS arrived patient hypotensive 70s over 40s with fever 102.5F (farentheit). Medics unable to oxygen saturation in the field and subsequently started [resident] on nonrebreather. In ED (emergency department) [resident] tachypneic and markedly hypotensive. Additional review of hospital record revealed vitals recorded as follows; April 9, 2023 at 1659 (4:59 p.m.) pulse 144 with respiration 40 but blood pressure no reading. April 9, 2023 at 1714 (5:14 p.m.) blood pressure reading of 76/45. Vitals taken at 1730 (5:30 p.m.) recorded as pulse 124, respirations 48, and blood pressure 95/54 and oxygen saturation (oxygen level in blood) was 94%. Further review of hospital record revealed section Physical Exam subsections Procedures and Critical care the following; treatment was necessary to treat or prevent imminent or life threatening deteroriation of the following conditions: Cardiac failure, CNS(Central Nervous System) failure or compromise, respiratory failure, renal failure, sepsis, shock and dehydration. Additional review of hospital record revealed ED Provider noted indicating, [resident] was in hospital within past 10 days for issues with orthostatic hypotension. Apparently this morning the [resident] appeared to be more lethargic. On EMS arrive, [resident] found to be febrile, hypotensive. [Resident] has an indwelling Foley (catheter) in place on arrival with a very small amount of bloody urine in teh bag. On Arrival [resident] temperature is 100.2. He is tachycardi. He is markedly hypotensive with an initial pressure being obtained 53 systolic manually. Upon removal of the old Foley, purulent urine was draining from the penis. A new Foley was placed and with this, a large return of purulent urine. The facility failed to ensure physician order and follow-up for hematuria was followed, and low blood pressure and elevated pulse rate were timely reported to the Resident's attending physician resulting in the harm of hospitalization, intubation, and admission to the Intensive Care Unit. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 3/22/23, 8/5/22 28 Pa Code 211.5(f) Clinical Records Previously cited 8/5/22 28 PA Code 211.10(a) Resident care policies Previously cited 8/5/22