**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the resident's physician when there was a significant change in the physical status, and when a decision for transfer of the resident from the facility was made for one (Resident #5) of 24 residents reviewed for notification of changes and transfer of the resident from facility to hospital. 1. The facility failed to have any physician orders for medications to control blood sugar for more than one month (1/27/23-2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 2. The facility failed to notify the physician of high blood sugar levels (greater than 300 mg/dL) on multiple occasions between 1/28/23-2/28/23 for Resident #5. 3. The facility failed to notify the physician when Resident #5 showed signs and symptoms of hyperglycemia. 4. The facility failed to notify the physician when Resident #5 was transferred to the hospital with a blood sugar of 537 mg/dL (normal range is 70-110 mg/dL). 5.The facility failed to follow their policy of physician notification of elevated blood sugars greater than 300 mg/dL. This failure resulted in Resident #5 having high blood sugars for one month (1/27/23-2/28/23), which were not treated by nursing staff, and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar of 537 mg/dL on 2/28/23 at 6:14 PM. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could place residents of the facility at risk for life-threatening medical conditions due to the facility's failure to notify the physician of a resident change in condition. The findings included: Observation of Resident #5 on 2/28/23 at 9:45 AM revealed that resident was lying in bed. Her husband was sitting in a chair next to her. Resident #5 had difficulty answering questions due to confusion. Resident #5's husband was trying to get the resident to eat breakfast, but Resident #5 refused to eat. Resident #5's husband expressed concern and said that this was not normal for the resident. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on [DATE]. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not recieve any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervison. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed that there was a care plan for diabetes with the goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the resident's normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of the hospital discharge orders dated 1/27/23 (resident was admitted [DATE]) indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of Resident #5's January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, [If] Blood Sugar [is] less than 70, call MD. [If] Blood Sugar is 70 to 150, give 0 Units. [If] Blood Sugar is 151 to 200, give 2 Units. [If] Blood Sugar is 201 to 250, give 4 Units. [If] Blood Sugar is 251 to 300, give 6 Units. [If] Blood Sugar is 301 to 350, give 8 Units. [If] Blood Sugar is 351 to 400, give 10 Units. [If] Blood Sugar is greater than 400, call MD. Review of the physician orders for Resident #5 revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 1/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 324 mg/dL. Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/09/23 revealed no documentation that the physician was notified of the elevated blood sugar of 332 mg/dL. Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/10/23 revealed no documentation that the physician was notified of the elevated blood sugar of 335 mg/dL. Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/14/23 revealed no documentation that the physician was notified of the elevated blood sugar of 356 mg/dL. Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/17/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/18/23 revealed no documentation that the physician was notified of the elevated blood sugar of 309 mg/dL. Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/20/23 revealed no documentation that the physician was notified of the elevated blood sugar of 377 mg/dL. Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/21/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/22/23 revealed no documentation that the physician was notified of the elevated blood sugar of 384 mg/dL. Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/23/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 306 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 375 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 304 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 421 mg/dL. Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/26/23 revealed no documentation that the physician was notified of the elevated blood sugar of 406 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 305mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477mg/dL. Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses who documented Resident #5's high blood sugar had reported these high blood sugars to MD T. Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. No medication was given for this high blood sugar. Review of progress notes dated 2/28/23 revealed the physician was not notified of the elevated blood sugar of 537 mg/dL. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . NP[AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review of progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477, nor any documentation that the physician was notified that Resident #5 was showing signs of hyperglycemia. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP 5] . Review revealed the physician was not notified about the change in condition and transfer to the hospital. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital on [DATE] because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. LVN R stated that she did not notify MD T of Resident #5's high blood sugars. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated, I don't know why she [Resident #5] wasn't on insulin. When asked if she knew what the facility policy was during the interview, LVN R stated No. In an interview on 03/02/23 at 12:10 PM MD T was unaware of the decline that led to Resident #5's hospitalization. MD T said, I think her sugars are usually well-controlled? I think she was on metformin or something I think that was discontinued in the hospital . I remember that her metformin was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023. The progress notes that I write are received by medical records . I was under the impression that the orders I gave were put into the chart. When asked about the high blood sugars that led to Resident #5's hospitalization, MD T said that she knew that Resident #5 had been having high blood sugars and did not know that Resident #5 had been sent to the hospital. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD T usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar on 2/28/23. I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, and it was 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. LVN P stated she did not know the facility policy for notifying the doctor for high blood sugars. In an interview on 03/02/23 at 01:01 PM LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD 2. She stated, I didn't know I had to. I asked another nurse what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. LVN E stated she did not know the facility policy for notifying the doctor for high blood sugars. In an interview on 03/02/23 at 01:05 PM ADON denied reporting Resident #5's high blood sugars to MD T, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow. The ADON was unable to identify what the blood sugar parameters were for Resident #5. The ADON stated she did not know the facility policy for notifying the doctor for high blood sugars. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility. He stated, .I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN BB] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN BB] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. In an interview on 03/02/23 at 02:11 PM ADM said that the best practice when a resident is admitted is: Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician Upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. In an interview on 03/04/23 at 02:46 PM LVN N said she was not sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident didn't receive any orders for diabetes medication I would think that it would be life-threatening. In an interview on 03/04/23 at 3:00 PM MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but could not remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with Interim DON, she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident doesn't receive any medication for diabetes, Interim DON said, There's a possibility they could go into diabetic ketoacidosis [a life-threatening condition]. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. In an interview on 3/06/23 at 4:51 PM LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when the resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall gets admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happens late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes didn't get diabetes medication, Well, eventually they would die. Review of personnel files for nurses who cared for Resident #5 revealed that most of the nurses who had documented high blood sugar for Resident #5 (LVN R, LVN O, LVN N, LVN P, LVN E, RN Q, DON, and ADON) had no documented training in either checking blood glucose or reporting change in condition. The personnel files of 2 nurses (Wound Care Nurse M and LVN BB) contained a skills check off form regarding checking blood glucose, but the form was not signed by either nurse. One nurse's personnel file (LVN CC) had skills check off forms for checking blood glucose and reporting a change in condition to the physician. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to report a resident's change in condition to the resident's physician. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. Review of facility's policy Physician and Other Communication/Change in Condition revised 10/16/17 reflected to improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition .3. Notify the physician of the change in medical condition (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 4. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the resident's/patient's condition .6. Patient's/residents family member/legal representative will be notified of any change in condition required an emergent transfer to the hospital. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. The POR was accepted on 03/04/23 at 4pm. The accepted POR reflected the following: Resident #5 is not currently in the facility. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE] to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 3/7/23 The administrator and members of nursing management, the Mobile Director of Nursing and the consulting Director of Nursing will be re-educated as a train the trainer by the clinical consultant regarding the following expectations: This will be completed on 3/3/23 The admission policy including the requirement that orders are to be entered into matrix completely and accurately Abuse and Neglect admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders and verified by the physician Matrix physician order entry training will be done for accurate and complete order entry. admission and readmission orders are to be validated by members of nursing management as part of the clinical meeting process and by charge nurse on the weekends including validation of accurate and complete entry into matrix When admitting a resident without nursing management or supervisor in the facility a second nurse will validate that orders on discharge summary/hospital admission / readmission orders have been entered into matrix completely and accurately and verified by a physician. If any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Licensed nurses, including agency nurses and new hires should appropriately identify, assess and document acute change in condition and notify the physician for further direction. Licensed nurses, including agency nurses and new hires should identify the signs and symptoms of hyper and hypoglycemia and blood sugars out of the range of ordered parameters or above 300 per policy and notify the physician for further direction Notification of responsible party for acute change in condition and significant order change When a change of condition is identified the medical record will be reviewed by the clinical management team for any opportunities for training and education. Mobile Director of Nursing and Interim Director of Nursing and Nursing Managers will be individually trained as train the trainer on Matrix order entry in order to complete training going forward on licensed nurses including prn and agency nurses. This will be completed on 3/3/23 by the Clinical Consultant. Licensed nurses including agency Nurses and new hires will be re-educated by the Interim Director of Nursing/Designee on the following: admission policy including the requirement that orders are to be entered into matrix completely and accurately admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders that have been verified by the physician Matrix physician order entry training will be completed on each licensed nurse including agency nurses and new hires for proficiency on physician order entry. No nurse shall admit a resident or receive a new order from a physician without completing this training. When admitting a resident without nursing management or supervisor in facility a second nurse is to validate that orders on discharge summary/hospital admission orders have been entered into matrix completely and accurately and if any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review, the facility failed to ensure each resident was free from neglect when the facility failed to provide care and services for treatment of diabetes for one resident (Resident #5) of 24 residents reviewed for neglect. Resident # 5 did not receive oral medications and insulin for treatment of diabetes from 01/27/23 to 02/28/23. The facility failed to have a system in place to ensure: 1) Physician orders were in place for medications to control blood sugar for more than one month (1/27/23 2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 2) Treatment was provided for elevated blood sugars equal to or greater than 300 mg/dL on multiple occasions for Resident #5. 3) Their policy of notifying the physician for elevated blood sugars equal to or greater than 300 mg/dL for Resident #5. 4) Treatment was provided when Resident #5 showed signs and symptoms of hyperglycemia. This failure resulted in Resident #5 having high blood sugars for one month (1/27/23-2/28/23), which were not treated by nursing staff, and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar on 2/28/23 at 6:14 PM. This failure could place residents of the facility at risk for neglect and could lead to serious injury, serious impairment, pain, mental anguish and death. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm because the facility was still monitoring the effectiveness of their Plan of Removal (POR). The findings included: Observation of Resident #5 on 2/28/23 at 9:45 AM revealed that resident was lying in bed. Her husband was sitting in a chair next to her. Resident #5 had difficulty answering questions due to confusion. Resident #5's husband was trying to get the resident to eat breakfast, but Resident #5 refused to eat. Resident #5's husband expressed concern and said that this was not normal for the resident. According to the National Library of Medicine (https://www.ncbi.nlm.nih.gov/books/NBK482142/), Hyperosmolar hyperglycemic syndrome (HHS) is a clinical condition that arises from a complication of diabetes mellitus. This problem is most commonly seen in type 2 diabetes. HHS is a serious and potentially fatal complication of type 2 diabetes . The mortality rate in HHS can be as high as 20%, which is about 10 times higher than the mortality seen in diabetic ketoacidosis. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on [DATE]. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not recieve any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervison. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed the following goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the resident's normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of hospital discharge orders dated 1/27/23 indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of Resident #5's January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, [If] Blood Sugar [is] less than 70, call MD. [If] Blood Sugar is 70 to 150, give 0 Units. [If] Blood Sugar is 151 to 200, give 2 Units. [If] Blood Sugar is 201 to 250, give 4 Units. [If] Blood Sugar is 251 to 300, give 6 Units. [If] Blood Sugar is 301 to 350, give 8 Units. [If] Blood Sugar is 351 to 400, give 10 Units. [If] Blood Sugar is greater than 400, call MD. Review of the physician orders for Resident #5 revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 1/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 324 mg/dL. Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/09/23 revealed no documentation that the physician was notified of the elevated blood sugar of 332 mg/dL. Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/10/23 revealed no documentation that the physician was notified of the elevated blood sugar of 335 mg/dL. Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/14/23 revealed no documentation that the physician was notified of the elevated blood sugar of 356 mg/dL. Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/17/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/18/23 revealed no documentation that the physician was notified of the elevated blood sugar of 309 mg/dL. Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/20/23 revealed no documentation that the physician was notified of the elevated blood sugar of 377 mg/dL. Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/21/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/22/23 revealed no documentation that the physician was notified of the elevated blood sugar of 384 mg/dL. Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/23/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 306 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 375 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 304 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 421 mg/dL. Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/26/23 revealed no documentation that the physician was notified of the elevated blood sugar of 406 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 305mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477mg/dL. Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses who documented Resident #5's high blood sugar had reported these high blood sugars to MD T. Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. No medication was given for this high blood sugar. Review of progress notes dated 2/28/23 revealed the physician was not notified of the elevated blood sugar of 537 mg/dL. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . NP[AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review of progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477, nor any documentation that the physician was notified that Resident #5 was showing signs of hyperglycemia. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP 5] . Review revealed the physician was not notified about the change in condition and transfer to the hospital. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated she did not know why the resident wasn't on insulin. In an interview on 03/02/23 at 12:10 PM with MD T , the doctor said, I remember that [Resident #5's] Metformin (a diabetes pill) was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023 . I was under the impression that the orders I gave were put into the chart. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD T usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar: I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. In an interview on 03/02/23 at 01:01 PM LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD T. I didn't know I had to. I asked another nurse what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. In an interview on 03/02/23 at 01:05 PM ADON denied reporting Resident #5's high blood sugars to MD 2, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow. The ADON was unable to identify what the blood sugar parameters were for Resident #5. The ADON said that the staff had been trained on neglect but was unable to say when the last training was. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility.I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN BB] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN BB] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. The DON said that the staff had been trained on neglect but was unable to say when the last training was. In an interview on 03/02/23 at 02:11 PM ADM said that the best practice when a resident is admitted is: Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician Upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. The administrator said he was not sure when the staff had last been trained on neglect. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. In an interview on 03/04/23 at 02:46 PM LVN N said she wasn't sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident didn't receive any orders for diabetes medication I would think that it would be life-threatening. In an interview on 03/04/23 at 3:00 PM MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but couldn't remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with Interim DON , she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident doesn't receive any medication for diabetes, There's a possibility they could go into diabetic ketoacidosis, which is a life-threatening condition. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. The Interim DON was able to explain what neglect was but was unsure when the nursing staff had last been trained on neglect. In an interview on 3/06/23 at 4:51 PM LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when the resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall gets admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happens late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes didn't get diabetes medication, Well, eventually they would die. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to report neglect to the appropriate authorities. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review of the facility policy titled Abuse, Neglect, Exploitation or Mistreatment (dated 10/01/2020) revealed the following statement, Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Review of facility's In-service Abuse and Neglect/Falls dated 01/31/23 by DON reflected staff were in-serviced on abuse and neglect. It reflected that LVN E, LVN I, LVN O, LVN P, LVN S, ADON, Wound Care Nurse M and RN U were all in-serviced on abuse/neglect policy. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. The POR was accepted on 03/04/23 at 4pm. The accepted POR reflected the following : Resident #5 is not currently in the facility. The allegation of neglect has been reported to the state agency and is being thoroughly investigated. Appropriate actions will be taken as the investigation is conducted. The results of the investigation will be submitted to the state agency in 5 days. The administrator will be re-educated by the Regional [NAME] President of Operations or the Clinical Consultant on timely reporting and investigation of allegations of abuse and neglect. This will be completed on 3/4/23. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE], to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 3/7/23 The administrator and members of nursing management, the Mobile Director of Nursing and the consulting Director of Nursing will be re-educated as a train the trainer by the clinical consultant regarding the following expectations: This will be completed on 3/3/23 The admission policy including the requirement that orders are to be entered into matrix completely and accurately Abuse and Neglect admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders and verified by the physician Matrix physician order entry training will be done for accurate and complete order entry. admission and readmission orders are to be validated by members of nursing management as part of the clinical meeting process and by charge nurse on the weekends including validation of accurate and complete entry into matrix When admitting a resident without nursing management or supervisor in the facility a second nurse will validate that orders on discharge summary/hospital admission / readmission orders have been entered into matrix completely and accurately and verified by a physician. If any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Licensed nurses, including agency nurses and new hires should appropriately identify, assess and document acute change in condition and notify the physician for further direction. Licensed nurses, including agency nurses and new hires should identify the signs and symptoms of hyper and hypoglycemia and blood sugars out of the range of ordered parameters or above 300 per policy and notify the physician for further direction Notification of responsible party for acute change in condition and significant order change When a change of condition is identified the medical record will be reviewed by the clinical management team for any opportunities for training and education. Mobile Director of Nursing and Interim Director of Nursing and Nursing Managers will be individually trained as train the trainer on Matrix order entry in order to complete training going forward on licensed nurses including prn and agency nurses. This will be completed on 3/3/23 by the Clinical Consultant. Licensed nurses including agency Nurses and new hires will be re-educated by the Interim Director of Nursing/Designee on the following: admission policy including the requirement that orders are to be entered into matrix completely and accurately. admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders that have been verified by the physician Matrix physician order entry training will be completed on each licensed nurse including agency nurses and new hires for proficiency on physician order entry. No nurse shall admit a resident or receive a new order from a physician without completing this training. When admitting a resident without nursing management or supervisor in facility a second nurse is to validate that orders on discharge summary/hospital admission orders have been entered into matrix completely and accurately and if any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction Residents displaying a change of condition should be assessed to identify the signs and symptoms of hyper and hypoglycemia and notify the physician for further direction The physician should be notified of blood sugars out of the range of ordered parameters or above 300 per policy. Any blood glucose monitoring when nursing management not in facility will be reviewed by 2nd nurse and signed as validated that it is within range or out of ordered parameters or above 300 and that physician is

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had admission physician orders for their immediate care for two residents (Resident #5 and Resident #173) of 24 residents reviewed for admitting physician orders. 1. The facility failed to reconcile hospital discharge orders for diabetes medication (insulin sliding scale) upon Resident #5's readmission to the facility from the hospital on 1/27/23. 2. The facility failed to have any physician orders for medications to control blood sugar for more than one month (1/27/23-2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 3. The facility failed to have physician orders for treatment of high blood sugar levels (greater than 300 mg/dL) on multiple occasions between 1/28/23-2/28/23 for Resident #5. 4. The facility failed to physician orders when Resident #5 showed signs and symptoms of hyperglycemia. This failure resulted in Resident #5 having no orders for diabetes medication, and no orders for the physician notification in the case of very high blood sugar for one month (1/27/23-2/28/23). This failure resulted in Resident #5 having frequent high blood sugars, which were not treated by staff and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar on 2/28/23 at 6:14 PM. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm that is not immediate jeopardy because the facility was still monitoring the effectiveness of their Plan of Removal (POR). 5. The facility failed to ensure Resident #173 had admitting physician orders for wound care for her pressure ulcer when she was admitted on [DATE] from the hospital. These failures could place all residents of the facility at risk for life-threatening medical conditions due to the facility's failure to notify the physician of a resident change in condition. The findings included: 1. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on [DATE]. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not receive any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervision. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed that there was a care plan for diabetes with the goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the residents normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of hospital discharge orders dated 1/27/23 indicated that Resident #5 had been discharged with an order for Insulin Lisper high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of the January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, Blood Sugar less than 70, call MD. Blood Sugar is 70 to 150, give 0 Units. Blood Sugar is 151 to 200, give 2 Units. Blood Sugar is 201 to 250, give 4 Units. Blood Sugar is 251 to 300, give 6 Units. Blood Sugar is 301 to 350, give 8 Units. Blood Sugar is 351 to 400, give 10 Units. Blood Sugar is greater than 400, call MD. Review of the physician orders revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. (Normal range is 70-110 mg/dL) Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM documented a blood sugar of 397 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. (Normal range is 70-110 mg/dL). Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. (Normal range is 70-110 mg/dL). Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses, who documented Resident #5's high blood sugar, reported these high blood sugars to MD T. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . [NP AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review revealed the physician was not notified of the elevated blood sugar of 477. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP 5] . Review revealed the physician was not notified about the change in condition. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated she did not know why the resident was not on insulin. LVN R was unsure of the facility policy for admission orders and was not sure if she had been trained by administration on physician order entry. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility.I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN BB] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN BB] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. LVN O said he hadn't received training from administration on physician order entry. In an interview on 03/02/23 at 12:10 PM with MD T, the doctor said, I remember that [Resident #5's] Metformin (a diabetes pill) was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023 . I was under the impression that the orders I gave were put into the chart. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD 2 usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar: I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. LVN P said she had not received training from administration on physician order entry. In an interview on 03/02/23 at 01:01 PM, LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD 2. I didn't know I had to. I asked another nurse [LVN R] what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. LVN E said she had not received training from administration on physician order entry. In an interview on 03/02/23 at 01:05 PM, the ADON denied reporting Resident #5's high blood sugars to MD T, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow . The ADON said she was not sure if staff had received training from administration on physician order entry. The ADON was unable to state what MD T's parameters were. The ADON chose not to answer the question, What would you consider a high blood sugar level? In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. The DON said she was not sure if staff had received training from administration on physician order entry. In an interview on 03/02/23 at 02:11 PM, the ADM said, Best practice? Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. ADM said he was not sure if staff had received training from administration on physician order entry. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. RN Q said she had not received training from administration on physician order entry. In an interview on 03/04/23 at 02:46 PM, LVN N said she was not sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident did not receive any orders for diabetes medication I would think that it would be life-threatening. LVN N said she had not received training from administration on physician order entry. In an interview on 03/04/23 at 3:00 PM, MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but couldn't remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with the Interim DON, she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident does not receive any medication for diabetes, There's a possibility they could go into diabetic ketoacidosis, which is a life-threatening condition. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. Interim DON said she was not sure if staff had received training from administration on physician order entry. In an interview on 3/06/23 at 4:51 PM, LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when a resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall got admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happened late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes did not get diabetes medication, Well, eventually they would die. LVN BB said she hadn't received training from administration on physician order entry. Review of personnel files for nurses who cared for Resident #5 revealed that most of the nurses who had documented high blood sugar for Resident #5 (LVN R, LVN O, LVN N, LVN P, LVN E, RN Q, DON, and ADON) had no documented training in order reconciliation or entry of physician orders. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to enter physician orders. Review of facility In-service admission Compliance dated 12/09/22 reflected LVN I, LVN P, LVN S, Wound Care Nurse M were in-serviced with a total of seven nurses that received this facility in-service. The in-service reflected under Admissions Instructions about a new resident to Alert the DON and physician that a pt [patient] is here and send med list to the physician. Physician may have changes to the med orders, or additional labs they want ordered, so be ready to make notes. 2. Input the med orders - if not done by 8 pm that day, meds will not arrive at midnight, and will be delayed until the next day . [patients] generally aren't too pleased about missed meds either Under medication orders it reflected about re-admitted patients that prior physician orders have to be discontinued and would have medication list in admittance/hospital pack that needed to be confirmed with the attending physician. It reflected all medications must be entered into electronic record and included instructions on how to input orders into the electronic record. Review of facility in-service Train the trainer dated 12/12/22 by Regional Nurse reflected 2. All nurses must complete training prior to next scheduled shift including agency. 3. Instructed on Audit tools and admission process and follow up. 4. ADONs will audit new admits within 24 hours Monday through Friday. Weekend Supervisor/Designees will audit Sat/Sunday. Management and Weekend will address concerns and provide education redirection of clinical if necessary. 5. ADON will validate using clinical meeting from M - F. Weekend Supervisor or Designee will validate using clinical meeting form assigned by DON. It reflected Staffing Coordinator (Previous ADON) and DON were in-serviced on 12/13/22. Review of facility In-service Admissions dated 12/12/22 by DON reflected Please follow the attached guidelines when new admission arrives. Assessment completed immediately All medication should be put in system before end of shift. Licensed Nurse will be re-educated on the admission process including the expectation that orders are to be transcribed and implemented as ordered. Licensed Nurse will utilize admission check list for guidance on completion and will have admission orders verified and validated by another nurse on the shift. This in-service reflected a sign-in sheet which included ADON, Wound Care Nurse M, LVN I, LVN P and LVN S. Review of facility's policy Physician Orders last revised 10/27/17 reflected The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines .admission: 1. The qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed .3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: A. Dietary orders B. Medications, if necessary C. Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan. Under Telephone and Verbal section it reflected 2. Record the actual order received from the physician. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested . The POR was accepted on 03/04/23 at 4pm. The accepted POR for admission physician orders reflected the following: Resident #5 is not currently in the facility. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE] to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction and the responsible party has been notified. This will be completed by 3/7/23 The administrator and members of nursing management, the Mobile Director of Nursing and the consulting Director of Nursing will be re-educated as a train the trainer by the clinical consultant regarding the following expectations: This will be completed on 3/3/23 The admission policy including the requirement that orders are to be entered into matrix completely and accurately Abuse and Neglect admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders and verified by the physician Matrix physician order entry training will be done for accurate and complete order entry. admission and readmission orders are to be validated by members of nursing management as part of the clinical meeting process and by charge nurse on the weekends including validation of accurate and complete entry into matrix When admitting a resident without nursing management or supervisor in the facility a second nurse will validate that orders on discharge summary/hospital admission / readmission orders have been entered into matrix completely and accurately and verified by a physician. If any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction. Licensed nurses, including agency nurses and new hires should appropriately identify, assess and document acute change in condition and notify the physician for further direction. Licensed nurses, including agency nurses and new hires should identify the signs and symptoms of hyper and hypoglycemia and blood sugars out of the range of ordered parameters or above 300 per policy and notify the physician for further direction Notification of responsible party for acute change in condition and significant order change When a change of condition is identified the medical record will be reviewed by the clinical management team for any opportunities for training and education. Mobile Director of Nursing and Interim Director of Nursing and Nursing Managers will be individually trained as train the trainer on Matrix order entry in order to complete training going forward on licensed nurses including prn and agency nurses. This will be completed on 3/3/23 by the Clinical Consultant. Licensed nurses including agency Nurses and new hires will be re-educated by the Interim Director of Nursing/Designee on the following: admission policy including the requirement that orders are to be entered into matrix completely and accurately admission and readmission orders are to be transcribed/entered into Matrix from the discharge summary or hospital admission orders that have been verified by the physician Matrix physician order entry training will be completed on each licensed nurse including agency nurses and new hires for proficiency on physician order entry. No nurse shall admit a resident or receive a new order from a physician without completing this training. When admitting a resident without nursing management or supervisor in facility a second nurse is to validate that orders on discharge summary/hospital admission orders have been entered into matrix completely and accurately and if any concern the Mobile Director of Nursing or Interim Director of Nursing is to be notified for further direction Residents showing signs of a change of condition should be assessed to appropriately identify and document the acute change in condition and notify the physician for further direction Residents displaying a change of condition should be assessed to identify the signs and symptoms of hyper and hypoglycemia and notify the physician for further direction The physician should be notified of blood sugars out of the range of ordered parameters or above 300 per policy Any blood glucose monitoring when nursing management not in facility will be reviewed by 2nd nurse and signed as validated that it is within range or out of ordered parameters or above 300 and that physician is notified. Notification of responsible party for acute change in condition Abuse Neglect and Misappropriation training This re-education will be initiated on 3/3/23 by the Interim Director of Nursing/designee. Any licensed nurse including Agency Nurses not receiving this education by the end 3/7/23 will receive prior to next scheduled shift. An employee roster will be utilized to track education compliance. Scheduled agency personnel will receive this re-education prior to working scheduled shift. This will also be presented in new hire orientation. Licensed Nurses including agency Nurses will not work until training completed. Agency nurse training will be tracked by the Mobile Director of Nursing or Interim Director of Nursing to valid[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan for one (Resident #5) of 24 residents reviewed for quality of care. 1. The facility failed to have any physician orders for medications to control blood sugar for more than one month (1/27/23-2/28/23) for Resident #5 (diagnosed with Diabetes Type 2). 2. The facility failed to notify the physician of high blood sugar levels (greater than 300 mg/dL) on multiple occasions between 1/28/23-2/28/23 for Resident #5. 3. The facility failed to notify the physician when Resident #5 showed signs and symptoms of hyperglycemia. 4. The facility failed to notify the physician when Resident #5 was transferred to the hospital with a blood sugar of 537 mg/dL (normal range is 70-110 mg/dL). 5. The facility failed to follow their policy of physician notification of elevated blood sugars great than 300 mg/dL. This failure resulted in Resident #5 having high blood sugars for one month (1/27/23-2/28/23), which were not treated by nursing staff, and not reported to Resident #5's physician. On 2/28/23 at 4:23 PM Resident #5 showed signs and symptoms of hyperglycemia (profuse sweating, flushed face, and clammy skin). Resident #5 was transferred to the hospital for elevated blood sugar on 2/28/23 at 6:14 PM. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. While the IJ was removed on 3/07/23 at 2:52 PM, the facility remained out of compliance at a scope of pattern at the severity level of actual harm because the facility was still monitoring the effectiveness of their Plan of Removal (POR). This failure could place all residents of the facility at risk for life-threatening medical conditions due to the facility's failure to notify the physician of a resident change in condition. The findings included: Observation of Resident #5 on 2/28/23 at 9:45 AM revealed that resident was lying in bed. Her husband was sitting in a chair next to her. Resident #5 had difficulty answering questions due to confusion. Resident #5's husband was trying to get the resident to eat breakfast, but Resident #5 refused to eat. Resident #5's husband expressed concern and said that this was not normal for the resident. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility from the hospital on [DATE]. She had diagnoses of sepsis (blood infection), hypertension (high blood pressure), Diabetes, Multiple Sclerosis (a degenerative neurological disease), and Kidney Failure . It reflected she did not receive any insulin injections. Review revealed the resident had a BIMS score of 13 which meant the resident was cognitively intact. The resident required extensive assistance to total dependence with all ADLs except eating only needed supervision. Resident #5 was incontinent of bowel and bladder. Review of the care plan dated 2/20/23 revealed that there was a care plan for diabetes with the goal statement, Diabetic status will remain stable as evidenced by residents [blood sugar] staying within the residents normal limits thru the next review date. Review of care plan revealed no statement as to the normal limits for Resident #5. Review of hospital discharge orders dated 1/27/23 indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of the January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, Blood Sugar less than 70, call MD. Blood Sugar is 70 to 150, give 0 Units. Blood Sugar is 151 to 200, give 2 Units. Blood Sugar is 201 to 250, give 4 Units. Blood Sugar is 251 to 300, give 6 Units. Blood Sugar is 301 to 350, give 8 Units. Blood Sugar is 351 to 400, give 10 Units. Blood Sugar is greater than 400, call MD. Review of the hospital discharge orders dated 1/27/23 (resident was admitted [DATE]) indicated that Resident #5 had been discharged with an order for Insulin Lispro high dose sliding scale. A written note at the bottom of the orders read, New orders added by [MD T]: check blood sugar BID. There were no orders for oral medication for diabetes. Review of Resident #5's January and February physician orders dated 03/02/23 revealed there were no orders for the treatment of diabetes (insulin sliding scale or oral medication) from 01/27/23 to 02/28/23. Review of physician order dated 03/01/23 revealed an order for insulin sliding scale that read, [If] Blood Sugar [is] less than 70, call MD. [If] Blood Sugar is 70 to 150, give 0 Units. [If] Blood Sugar is 151 to 200, give 2 Units. [If] Blood Sugar is 201 to 250, give 4 Units. [If] Blood Sugar is 251 to 300, give 6 Units. [If] Blood Sugar is 301 to 350, give 8 Units. [If] Blood Sugar is 351 to 400, give 10 Units. [If] Blood Sugar is greater than 400, call MD. Review of the physician orders for Resident #5 revealed an order dated 2/03/23 that read, Check blood sugar BID. There was no order to notify the physician for high blood sugars. Review of TAR for Resident #5 indicated that on 1/28/23 at 5:00 PM LVN E documented a blood sugar of 324 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 1/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 324 mg/dL. Review of TAR for Resident #5 indicated that on 2/09/23 at 4:00 PM LVN E documented a blood sugar of 332 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/09/23 revealed no documentation that the physician was notified of the elevated blood sugar of 332 mg/dL. Review of TAR for Resident #5 indicated that on 2/10/23 at 4:00 PM LVN E documented a blood sugar of 335 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/10/23 revealed no documentation that the physician was notified of the elevated blood sugar of 335 mg/dL. Review of TAR for Resident #5 indicated that on 2/14/23 at 4:00 PM DON documented a blood sugar of 356 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/14/23 revealed no documentation that the physician was notified of the elevated blood sugar of 356 mg/dL. Review of TAR for Resident #5 indicated that on 2/17/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/17/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/18/23 at 4:00 PM LVN E documented a blood sugar of 309 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/18/23 revealed no documentation that the physician was notified of the elevated blood sugar of 309 mg/dL. Review of TAR for Resident #5 indicated that on 2/20/23 at 4:00 PM LVN E documented a blood sugar of 377 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/20/23 revealed no documentation that the physician was notified of the elevated blood sugar of 377 mg/dL. Review of TAR for Resident #5 indicated that on 2/21/23 at 4:00 PM ADON documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/21/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/22/23 at 4:00 PM LVN E documented a blood sugar of 384 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/22/23 revealed no documentation that the physician was notified of the elevated blood sugar of 384 mg/dL. Review of TAR for Resident #5 indicated that on 2/23/23 at 4:00 PM LVN E documented a blood sugar of 400 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/23/23 revealed no documentation that the physician was notified of the elevated blood sugar of 400 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 7:00 AM LVN R documented a blood sugar of 306 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 306 mg/dL. Review of TAR for Resident #5 indicated that on 2/24/23 at 4:00 PM LVN E documented a blood sugar of 375 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/24/23 revealed no documentation that the physician was notified of the elevated blood sugar of 375 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 7:00 AM RN Q documented a blood sugar of 304 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 304 mg/dL. Review of TAR for Resident #5 indicated that on 2/25/23 at 4:00 PM RN Q documented a blood sugar of 421 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/25/23 revealed no documentation that the physician was notified of the elevated blood sugar of 421 mg/dL. Review of TAR for Resident #5 indicated that on 2/26/23 at 4:00 PM LVN N documented a blood sugar of 406 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/26/23 revealed no documentation that the physician was notified of the elevated blood sugar of 406 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 7:00 AM LVN R documented a blood sugar of 305 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 305 mg/dL. Review of TAR for Resident #5 indicated that on 2/27/23 at 4:00 PM LVN E documented a blood sugar of 397 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/27/23 revealed no documentation that the physician was notified of the elevated blood sugar of 397 mg/dL. Review of TAR for Resident #5 indicated that on 2/28/23 at 7:00 AM LVN P documented a blood sugar of 477 mg/dL. No medication was given for this high blood sugar. Review of the progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477 mg/dL. Review of nursing progress notes for the period of 1/27/23 through 2/27/23 revealed that none of the seven facility nurses who documented Resident #5's high blood sugar had reported these high blood sugars to MD T. Review of TAR for Resident #5 indicated that on 2/28/23 at 4:00 PM LVN E documented a blood sugar of 537 mg/dL. No medication was given for this high blood sugar. Review of progress notes dated 2/28/23 revealed the physician was not notified of the elevated blood sugar of 537 mg/dL. Review of nursing progress note for Resident #5 dated 2/28/23 at 4:23 PM by LVN P read in part, blood sugar check this morning 477 . NP[AA] informed of blood sugar with new order for Lispro on [sliding scale] . At about 1pm this nurse noted individual having [signs and symptoms] of hyperglycemia . shaky . clammy . checked blood sugar which was 481 . Review of progress notes dated 2/28/23 revealed no documentation that the physician was notified of the elevated blood sugar of 477, nor any documentation that the physician was notified that Resident #5 was showing signs of hyperglycemia. Review of nursing progress note for Resident #5 dated 2/28/23 at 6:14 PM by LVN E read in part, Resident was sent to hospital as requested by both DON and [NP AA] . Review revealed the physician was not notified about the change in condition and transfer to the hospital. Interview with LVN R on 03/02/23 at 11:07 AM revealed Resident #5 was admitted to the hospital because she had a really high blood sugar. LVN R stated the resident was not receiving insulin. Interview revealed the facility just ordered insulin for Resident #5 on the morning of 02/28/23. LVN R stated she did not know why the resident wasn't on insulin. LVN R stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 12:10 PM with MD T, the doctor said, I remember that [Resident #5's] Metformin (a diabetes pill) was discontinued in the hospital due to kidney failure. I know that I gave the order for Metformin and for Novolog Lispro sliding scale as well as accu-checks AC and HS on February 3, 2023 . I was under the impression that the orders I gave were put into the chart. In an interview on 03/02/23 at 12:31 PM with NP AA (MD T's nurse practitioner), NP AA denied knowledge of Resident #5's high blood sugars, The first I heard of [the high blood sugars] was the day [Resident #5] was admitted to the hospital. NP AA said that MD T usually reviewed the laboratory results and denied knowledge that Resident #5 had no orders in her chart for diabetic medication from 1/27/23 to 2/28/23. In an interview on 03/02/23 at 12:41 PM, LVN P said she first discovered Resident #5's high blood sugar: I found that [on 2/28/23] the blood sugar was 477, I notified the doctor who ordered 10 units of insulin per sliding scale. I gave [Resident #5] 10 units before lunch. She looked flushed so I checked her sugar again . I checked it, 397 . When I re-checked it and the machine just said 'high' . To me, she didn't have a sliding scale. I called the doctor because she was trending high. I was shocked that nobody else intervened when the blood sugar was high. I didn't see no sliding scale, so I reached out to the physician. When she looked flushed, cool and clammy, I stayed in contact with the doctors . the doctor was saying she's hospice and the hospice nurse was saying to contact the doctor . her blood sugars were fine until recently. LVN P stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:01 PM LVN E denied reporting Resident #5's high blood sugars to Resident #5's physician, MD T. I didn't know I had to. I asked another nurse what I should do and she told me not to worry about it. Per nurse, she had graduated from nursing school 2 months ago. When asked if she learned how to monitor blood sugar in nursing school, nurse said yes. LVN E stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:05 PM ADON denied reporting Resident #5's high blood sugars to MD 2, saying, .depends on who the doctor is, what the parameters are . Each doctor has parameters that they follow. The ADON was unable to identify what the blood sugar parameters were for Resident #5. The ADON stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:11 PM LVN O (the nurse who admitted Resident #5 from the hospital on 1/27/23) said he did not frequently work at the facility.I go once a month, once every 2 weeks. I haven't been there in three weeks. LVN O said he remembered admitting Resident #5, The DON asked me if I could do an admission and I said I would try . I tried to enter the order, but I was having trouble with the eMAR because I hadn't done an admission for a while. I passed on in report to [LVN 7] that I wasn't done with the admission yet and I needed help finishing the orders. I told [LVN 7] 'this is what I reviewed, and this is what I did. This is what needs to be done by the ADON and DON and can you please pass it on in the morning.' The patient came in at about 8pm. I stayed late to finish the admission to do as much as I could do. I passed it on in report assuming that the DON and ADON would finish the admission. They are supposed to review the chart to make sure everything is up to date and correct. LVN O stated he didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 01:22 PM the DON said, The nurses, the DON, and the ADON are responsible for ensuring orders on newly admitted residents are entered into the eMAR. The nurses, and ADON and the DON are supposed to review the discharge orders. Every morning, we review the charts to make sure everything is correct. The DON said that a blood sugar level of 200 would prompt her to contact the resident's physician but was unsure why she did not contact the physician, saying, I would have to check my notes. DON stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/02/23 at 02:11 PM ADM said that the best practice when a resident is admitted is: Receiving nurse sees orders, clarifies orders with physician, and they go into effect. Best practice is during Interdisciplinary Team meeting and during care planning. The ADM said that the DON or ADON is responsible for making sure new orders are entered, and that nurses should contact the physician Upon recognizing that there has been a change of condition . When there is something that continues to be not normal, the nursing staff should report it to the physician . I recognize there are things that need to be addressed. ADM stated he didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/04/23 at 02:14 PM with RN Q, the nurse said she had been working at the facility for 1 week. The nurse who was supposed to be training her (LVN N) just left me alone without any guidance. I'm supposed to be still on orientation training, and I don't know these people. RN Q was unable to recall what happened on 2/25/23, when she documented a blood sugar of 305 mg/dL. RN Q stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/04/23 at 02:46 PM LVN N said she wasn't sure when to notify the physician of a resident's high blood sugar: I wasn't educated on that. I don't know if there's a policy. LVN N went on to say, I know that [a blood sugar of] 500 is dangerous . I know that 400 is of some concern, but we would monitor for signs and symptoms. LVN N denied contacting the physician on 2/26/23 when she documented a blood sugar level of 406 for Resident #5.I monitored for signs and symptoms. LVN N confirmed that there was no sliding scale in place for Resident #5, There was only an order for blood sugar checks BID. LVN N also said that she did not see any orders for diabetes medication on Resident #5's chart. LVN N said that if a diabetic resident didn't receive any orders for diabetes medication I would think that it would be life-threatening. LVN N stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 03/04/23 at 3:00 PM MD T said that if a resident had high blood sugar, I would expect [the facility] to inform me if anyone has a high blood sugar. MD T said she wanted to be notified of any resident who had a blood sugar over 400, according to the sliding scale orders. MD T said she first became aware of Resident #5's high blood sugars and subsequent hospital admission, When the surveyor called me [on 3/02/23]. MD T said that she saw Resident #5 on approximately February 3 or 4,, 2023, I gave an order for Metformin around February 4th, when I saw her after she got back from the hospital. Her creatinine was normal, so I wrote the order for Metformin . I thought she was on sliding scale, because I think that she came back from the hospital on sliding scale. MD T denied checking the chart to see if Resident #5 had orders for diabetes medication. MD T said her next visit to Resident #5 was on February 10 or 11, I gave orders for Metformin then as well because I saw it wasn't entered in Resident #5's chart. MD T said she gave verbal orders for Metformin but couldn't remember which nurse she gave them to. The second time I specifically talked to the nurse and told her I didn't see the order for Metformin in the computer, so I was going to give another order. In an interview on 3/04/23 at 03:18 PM with Interim DON, she explained how she would know when to report high blood sugar to the resident's physician: I look at the parameters. I look at the Resident's orders. If they don't have an order, I would call the physician if the blood sugar was over 110 or below 70. When a resident gets admitted from the hospital, I look at the hospital orders and I call the doctor and make sure that they want to continue the orders. The Interim DON was unable to describe facility protocol for making sure physician orders are entered into the e-chart, Well that's in development. Sometimes the doctor enters the orders in the computer. Sometimes they give us written orders. Sometimes they give a verbal order. If a diabetic resident doesn't receive any medication for diabetes, There's a possibility they could go into diabetic ketoacidosis, which is a life-threatening condition. The Interim DON also said that a resident could develop pressure ulcers (bed sores) if the resident's blood sugar was not being medically managed. Interim DON stated she didn't know the facility policy on notifying the MD for elevated blood sugars. In an interview on 3/06/23 at 4:51 PM LVN BB explained what resident blood sugar levels would prompt her to call the resident's physician: It's between 400 and 450, whichever the sliding scale is. If the resident didn't have a sliding scale, I'd have to call the physician and get a sliding scale if one wasn't ordered. LVN BB stated that when the resident is admitted to the facility, the resident's nurse is responsible for making sure orders get entered into the computer. If a resident on her hall gets admitted right before her shift, LVN BB said, If it's my resident I make sure the orders are entered, because I want to make sure their medication is on the way before I leave . First, I gotta call the doctor to get everything reconciled, and then I gotta put the orders in. If the admission happens late at night, I have to call [the physician] and wake them up. LVN BB said that she had experienced difficulty contacting MD T: Well, she's a doctor but she hates being woken up. She will snap at you but if you gotta call you gotta call. If a resident with diabetes didn't get diabetes medication, Well, eventually they would die. LVN BB stated she didn't know the facility policy on notifying the MD for elevated blood sugars. Review of personnel files for nurses who cared for Resident #5 revealed that most of the nurses who had documented high blood sugar for Resident #5 (LVN R, LVN O, LVN N, LVN P, LVN E, RN Q, DON, and ADON) had no documented training in either checking blood glucose or reporting change in condition to the physician. The personnel files of 2 nurses (Wound Care Nurse M and LVN BB) contained a skills check off form regarding checking blood glucose, but the form was not signed by either nurse. One nurse's personnel file (LVN CC) had skills check off forms for checking blood glucose and reporting a change in condition to the physician. Review of job descriptions for LVN, RN, DON, and ADON positions revealed that each required the nurse to report a resident's change in condition to the resident's physician. Review of facility In-service admission Compliance dated 12/09/22 reflected LVN I, LVN P, LVN S, Wound Care Nurse M were in-serviced with a total of seven nurses that received this facility in-service. The in-service reflected under Admissions Instructions about a new resident to Alert the DON and physician that a pt [patient] is here and send med list to the physician. Physician may have changes to the med orders, or additional labs they want ordered, so be ready to make notes. 2. Input the med orders - if not done by 8 pm that day, meds will not arrive at midnight, and will be delayed until the next day . [patients] generally aren't too pleased about missed meds either Under medication orders it reflected about re-admitted patients that prior physician orders have to be discontinued and would have medication list in admittance/hospital pack that needed to be confirmed with the attending physician. It reflected all medications must be entered into electronic record and included instructions on how to input orders into the electronic record. Review of facility in-service Train the trainer dated 12/12/22 by Regional Nurse reflected 2. All nurses must complete training prior to next scheduled shift including agency. 3. Instructed on Audit tools and admission process and follow up. 4. ADONs will audit new admits within 24 hours Monday through Friday. Weekend Supervisor/Designees will audit Sat/Sunday. Management and Weekend will address concerns and provide education redirection of clinical if necessary. 5. ADON will validate using clinical meeting from M - F. Weekend Supervisor or Designee will validate using clinical meeting form assigned by DON. It reflected Staffing Coordinator (Previous ADON) and DON were in-serviced on 12/13/22. Review of facility In-service Admissions dated 12/12/22 by DON reflected Please follow the attached guidelines when new admission arrives. Assessment completed immediately All medication should be put in system before end of shift. Licensed Nurse will be re-educated on the admission process including the expectation that orders are to be transcribed and implemented as ordered. Licensed Nurse will utilize admission check list for guidance on completion and will have admission orders verified and validated by another nurse on the shift. This in-service reflected a sign-in sheet which included ADON, Wound Care Nurse M, LVN I, LVN P and LVN S. Review of facility policy (dated 10/16/17) titled Physician and Other Communication/Change in Condition read in part, Glucose . Follow specific physician orders if present; or > 300mg/dL in diabetic patient not using sliding scale insulin; or >450 mg/dL (or machine registers high) in diabetic patient using sliding scale insulin . Review revealed the physician was to be notified of blood sugars greater than 300 mg/dL in a diabetic resident not using insulin sliding scale and 450 mg/dL ( or blood glucose monitoring registers high) in diabetic residents using an insulin sliding scale. Review of facility's policy Physician and Other Communication/Change in Condition revised 10/16/17 reflected to improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition .3. Notify the physician of the change in medical condition (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 4. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the resident's/patient's condition .6. Patient's/residents family member/legal representative will be notified of any change in condition required an emergent transfer to the hospital. Review of facility's policy Physician Orders last revised 10/27/17 reflected The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines .admission: 1. The qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity. 2. A call is placed to the physician to confirm the orders and request any additional orders as needed .3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: A. Dietary orders B. Medications, if necessary C. Routine care orders to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan. Under Telephone and Verbal section it reflected 2. Record the actual order received from the physician. An Immediate Jeopardy (IJ) situation was identified on 03/02/23 at 4:15 PM. The ADM was notified, and a POR was requested. The POR was accepted on 03/04/23 at 4pm. The accepted POR for quality of care reflected the following: Resident #5 is not currently in the facility. Residents who are admitted or readmitted to the facility or have a change of condition or Diabetic have the potential to be affected by this alleged deficient practice. Director of Nursing resigned and notice accepted on 3/3/23. Interim Director of Nursing in place and Mobile Director of Nursing will start 3/6/23. Agency checklist will be reviewed and revised to include the admission process, order entry, change in condition and monitoring of blood sugars and notification of physician when out of parameters or above 300. This will be completed by clinical consultants by 3/7/23 A house wide audit of admission or readmission orders on current residents admitted or readmitted [DATE] to 3/2/23 will be conducted by Director of Nursing / designee to validate that orders were transcribed /entered into matrix as ordered from the discharge summary or hospital discharge orders. Residents with diagnosis of diabetes will be audited by the Director of Nursing / designee to validate that orders for sliding scale, diabetic medications have been transcribed/entered into matrix and implemented accurately per physician orders. Any resident with a diagnosis of diabetes will be reviewed to validate that appropriate monitoring of blood sugars and oral diabetic medications or insulin have been ordered. If no orders noted, the physician will be notified for further direction. Any concern identified will be addressed at the time of discovery including notification of physician for further direction. This will be completed by 3/7/23. A house wide audit will be completed of sliding scale results and lab tests for blood glucose to validate that any result out of range has been reported to the physician for further direction. This will be completed by the Interim Director of Nursing or Mobile Director of Nursing/ designee by 3/7/23 The facility activity report and the 24-hour report for the past 72 hours