**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #35) of 8 residents reviewed for parameters to notify Physician of critical lab levels The facility failed to notify Resident # 35's primary care physician of critical low blood sugar readings of (46 mg/dl on 05/17/23 and 44mg/dl, on 05/21/23). The facility failed to train the staff of when to report changes to the physician. An Immediate Jeopardy (IJ) situation was identified on 06/13/23 at 3:00 PM. The IJ template was provided to the facility on [DATE] at 3:03pm. While the IJ was removed on 06/14/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death. Findings included: Record review of Resident # 35's face sheet dated 04/25/23 indicated Resident #35 admitted [DATE]. and was a 59-year- old-female with diagnosis: Bacteremia (blood infection, sepsis), Diabetes Mellitus a disease that occurs when your blood glucose, also called blood sugar, is too high (abnormal blood sugars) due to underlying condition with neuropathy, chronic viral hepatitis C, (liver disease),neuromuscular dysfunction of the bladder,(bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation, (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus, (pressure sore). Record review of the Physician Orders for Resident #35 dated 04/25/2023: Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicated, there were no physician orders to check resident #35's BS even though nurses were checking BS before administering Insulin. Resident #35 had no parameters for notification of critical BS values to be reported to the physician. Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS (activities of daily living), and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident was able to feed herself with set up assistance from staff. Resident had a foley catheter due to diagnosis of neuromuscular bladder, (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx and was incontinent of bowel. Record review of a care plan dated 05/31/23 indicated Resident #35 had diagnosis of Diabetes Mellitus, and intervention of: medications as ordered. Record review of Resident #35's progress note dated 05/17/23 at 10:44PM completed by CCM, (previous MDS coordinator) indicated CMS entered room for routine check, resident complained of, my sugar is dropping. Resident #53's Accucheck, (blood glucose monitor) Blood Sugar was 46mg/dl, glass of apple juice with sugar and bowl of cereal with milk given at this time, assisted resident to reposition in bed, Resident requested fan at the foot of the bed to be turned on, this nurse turned on fan as requested, hob elevated and snack set up, resident sitting up in bed eating cereal and drinking juice at this time. The progress note did not indicate that the Physician was notified of critical low blood sugar levels. 11:00 PM Entered room for follow up Accucheck BS 66. Noted to be lying in bed, awake and alert, respiration even and unlabored, skin warm/dry. Offered and accepted package of peanut butter crackers. No signs/symptoms of distress noted, resident states I feel a lot better now, just hungry, but I really like these crackers. Resident encouraged to consume package of crackers and assisted to reposition self and linens in bed for comfort. 11:29PM Repeat Accucheck BS level 82. Noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. No s/s of distress noted. Arouses easily to verbal stimuli, Resident stated, Thank you for everything, I feel better. Record review of a progress note dated 05/21/23 at 10:00AM indicated the Treatment Nurse was called to Resident #35's room to check blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes BS 80mg/dl. WCTM. Wound treatment provided this shift. PRN Tylenol #4 administered prior to treatment. Resident tolerated well no complaints. Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, results 130. Stated her thanks to this writer and Good, it should not drop much lower Record review of a progress note dated 05/24/23 at 2:15AM Called to room by resident requesting this nurse, (CCM) to, check my sugar, Accucheck BS level 66. Resident offered and accepted small package of peanut butter crackers at this time. No s/s of distress noted. Record Review of Consultant Pharmacist's Medication Regimen review dated 5/23 indicated there were no recommendations from the Pharmacist for Glucagon, (Hormone, it can treat severe low blood sugar) or parameters for notification to the Physician of critical values. During an interview 06/12/23 at 3:45 PM, Resident # 35 said she had tried to get the nurses to not give her full dosage of Insulin and to only give half, because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar dropping. A Record Review of Residents #35 progress notes dated 06/12/23 at 4:11 PM, order received for blood sugar checks BID, but still no parameters to hold Insulin, notify the Physician or Glucagon Orders. During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had worked for corporation for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at documentation. She was not aware there were no orders for blood sugars or parameters to hold Insulin on Resident #35. She said she had texted the Physician regarding the Resident's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed by her this morning with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility was for the nurses to follow morning meeting process, monitor vital signs, blood sugars and if out of range notify the Physician. She said she would monitor this when she comes to the facility twice a week. She said she would join the meeting through TEAMS. She said everyone taking Insulin will have BS checks, and parameters to hold Insulin if BS was to low or high and orders to notify the Physician. During a phone interview on 06/13/23 at 9:44 AM, the Physician said, (the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl). The Physician said he would call orders to the facility to notify him if blood sugars were below 100mg/dl. During an interview 06/13/23 at 10:03AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident has a critical lab value. She said resident #35 had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at nursing facility were not aware of sliding scale order. She said she had texted the Doctor multiple times since yesterday when they became aware of no parameters, and physician has not replied. LVN A, said she had notified Physician regarding Resident #35's scheduled Humulin Insulin at bedtime to see if facility could get orders for The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included: Notification of Changes. Resident #35: Resident's physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 5/17/23 and 5/21/23. New orders received for labs to include hemoglobinA1C, one time order, and accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. Date: 6/12/2023. Resident on 6/13/2023 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. Medical Director, was consulted regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar check orders to: Accuchecks BID, Special Instructions: **NOTIFY MD FOR BLOOD SUGARS <80 OR >400** Twice A Day 06:30 AM, 08:00 PM Blood sugar prn for symptoms of hyperglycemia or hypoglycemia. Special Instructions: Notify MD of results <80 or >400 As Needed PRN 1, PRN 2, PRN 3 Notification parameters have added to all residents with finger stick blood sugar orders per the MD's request. Action 1: Educate all nurses regarding physician notification and change of condition. The licensed nursing staff will have an understanding to report out of range (less than 80 and higher than 400)/critical blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per physician order). Staff will have an understanding on when to report changes to the physician through the above education physician notification and change of condition. All current, new and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. Out of range, per the Medical Director, that he would like notified about, is lower than 80 and higher than 400. These parameters have been added to the accucheck orders. Date of Completion: 6/14/2023 by 11AM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 2: Clinical Resource Nurse and/or Clinical Company Leader to perform blood sugar audit to check for out of range blood sugars for previous 30-days. Any blood sugars identified outside the Physician Prescribed range per his order(s) will be reported to the Medical Director and any new orders received will be entered and followed. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse and/or Clinical Company Leader Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. Clinical Resource Nurse and Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Per the Medical Director he would like to be notified of blood sugar outside the range of 80-400, this reflects in the order set inputted for residents receiving accuchecks. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse Action 4: Adhoc QAPI meeting performed with interim administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents. Date of Completion: 6/13/2023 Staff Responsible for Completion: Administrator and Clinical Resource Nurse On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test. Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl. On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 of 8 residents (Resident #35), reviewed for quality of care. The facility failed to obtain orders for finger stick blood sugars for resident #35 and to follow their policy on Management of Hypoglycemia, (low blood sugar), when resident # 35's blood sugar reading was at critical levels of 46mg/dl on 05/17/23 and 44mg/dl on 05/23/23 and hold parameter for Insulin if blood sugar reading is at a critical level of below 70mg/dl. Resident #35 experienced sweating and shakiness when her blood sugar fell below 80mg/dl. Resident #35 had no orders for finger stick blood sugars and no parameters for holding Insulin for blood sugar levels below 70mg/dl. An Immediate Jeopardy (IJ) situation was identified on 06/13/23. The IJ template was provided to the facility on [DATE] at 3:03pm, while the IJ was removed on 06/14/23. The facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm, due to the facility's need to evaluate the corrective actions. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment, or death. Findings included: Record review of Resident #35's face sheet dated 04/25/23 indicated Resident #35 admitted to the facility on [DATE] and was a 59-year- old-female with diagnoses: Bacteremia (blood infection, sepsis), Diabetes Mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), (abnormal blood sugars) due to underlying condition with neuropathy, (dysfunction of peripheral nerves), (chronic viral hepatitis C (liver disease), neuromuscular dysfunction of the bladder (bladder muscles don't work right), muscle wasting and atrophy, atrial fibrillation (abnormal heart beat), gastro-esophageal reflux disease without esophagitis and a stage four decubitus (pressure sore). Record review of Physician Orders dated 04/25/2023 Humulin 70/30 U-100 Insulin (Insulin NPH and Regular Human) suspension; 100 unit/ml (70-30); amt:20 units; subcutaneous [DX: Diabetes Mellitus due to underlying condition with diabetic neuropathy, unspecified] twice a day; 0700AM, 8:00 PM. Further review of the physician orders indicates, there were no physician orders to check resident's BS and no parameters for notification of abnormal values to be reported to the physician. Record review of a MDS dated [DATE] indicated Resident #35 had intact cognition, was understood by others, and able to understand others. She required one-person, total assistance with most ADLS, and two-person assistant and use of the Hoyer lift for transfers. She utilized a wheelchair for mobility. Resident #35 was able to feed herself with set up assistance from staff. Resident #35 had a Foley catheter due to diagnosis of neuromuscular bladder (lack of bladder control), a stage four decubitus, (pressure sore) to her coccyx (small triangular bone at the base of the spine) and was incontinent of bowel. Record review of a care plan dated 05/31/23 indicated Resident #35 had a diagnosis of Diabetes Mellitus, and intervention of: medications as ordered. Record Review of Physician orders dated 04/25/23 through 06/12/23 indicated Resident #35 had no orders for routine finger stick blood sugars, no parameters to hold insulin if blood sugar reading below 70mg/dl, and no orders to notify the physician of critical blood sugar levels of below 70mg/dl and above 250 mg/dl. Record review of MAR (medication administration record) indicates nurses were checking residents BS twice a day before Insulin administration but had no Physician orders to check Resident's BS and no parameters to hold Insulin or parameters to notify the Physician of critical values. Record review of Resident #35's progress note dated 05/17/23 at 10:44 PM completed by the CCM (previous MDS coordinator) indicated the CCM entered the room for a routine check and the resident complained of, my sugar is dropping. Resident #35's Accucheck (blood glucose monitor) Blood Sugar was 46mg/dl. A glass of apple juice with sugar and a bowl of cereal with milk was given at that time. The resident was assisted to reposition in bed. The resident requested a fan at the foot of the bed to be turned on, and the nurse turned on the fan as requested. The head of bed was elevated, and a snack was set up. The resident was sitting up in bed eating cereal and drinking juice at this time. At 11:00 PM, CCM entered room for follow up Accucheck, BS at 66. Resident noted to be lying in bed, awake and alert, respiration even and unlabored, skin was warm/dry. The resident was offered and accepted a package of peanut butter crackers. There were no signs/symptoms of distress noted, and the resident stated she felt a lot better now, was just hungry, but he really like the crackers. The resident was encouraged to consume package of crackers and was assisted to reposition self and linens in bed for comfort. At11:29 PM a repeat Accucheck, BS level 82. The resident was noted to be lying in bed with eyes closed, resting quietly, respiration even and unlabored, skin warm/dry. There was no signs/symptoms of distress noted. The resident aroused easily to verbal stimuli. The resident stated, Thank you for everything, I feel better. Record review of a progress note dated 05/21/23 at 10:00 AM indicated the Treatment Nurse was called to Resident #35's room to check his blood sugar due to signs of hypoglycemia. Accucheck BS was 44mg/dl. Gave 4oz. of orange juice and crackers/sandwich. Rechecked after 30 minutes and BS 80mg/dl. WCTM. Wound treatment was provided on shift. PRN Tylenol #4 was administered prior to treatment. The resident tolerated well no complaints. Record review of a progress note dated 05/24/23 at 12:25AM, Resident #35 requested Accucheck BS, and results were 130mg/dl. Stated her thanks to this writer (CCM) and Good, it should not drop much lower. Record review of a progress note dated 05/24/23 at 2:15 AM CCM called to resident #35's room by resident, requesting this nurse, (CCM) to, check my sugar, Accucheck BS was level 66. The resident was offered and accepted a small package of peanut butter crackers at the time. There were no signs/symptoms of distress noted. Record Review of the Consultant Pharmacist's Medication Regimen Review dated May 2023 indicated there were no recommendations from the Pharmacist for Glucagon, (hormone, it can treat severe low blood sugar,) parameters to hold insulin, or parameters for notification to the Physician of critical values. During an interview on 06/12/23 at 3:45 PM, Resident #35 said she had tried to get the nurses to not give her a full dosage of Insulin 20mg/dl and to only give half (10mg/dl) because her blood sugar kept dropping. She said as far as she knew the Physician had not been notified of her blood sugar dropping. She said she has seen the Physician but didn't think to tell him. Resident #35 said she experienced sweating and shakiness when her blood sugar fell below 80mg/dl. During an interview on 06/12/23 at 4:00 PM, the Regional Nurse said she had notified the Physician regarding the Resident #35's blood sugars and requested a medication review, but he had not responded. She said Resident #35 had been assessed with no signs or symptoms of Hypoglycemia. The Regional Nurse said she had worked for corporate for two years. She said she had four buildings and two of them were without a DON. She said when she comes to the building, she looks at 72-hour report and does any needed in-services. She does skill checks and looks at incidents and accidents. During the morning meeting she looks at nursing documentation. She was not aware there were no orders for blood sugars or parameters to hold insulin for Resident #35. During an interview 6/12/23 a 4:10 PM, the Regional nurse said Resident #35 had been assessed today with no signs or symptoms of Hypoglycemia. She said the resident could go into a coma if blood sugar was too low. She said her expectations for the facility is for the nurses to follow the morning meeting process, (look at documentation, monitor vital signs, blood sugars and if out of range to notify the Physician). She said she would join the meeting through TEAMS. (Messaging APP). She said everyone taking insulin will have BS checks, and parameters to hold Insulin if BS is to low or high. Record Review of a Progress notes dated 06/12/23 at 4:11 PM revealed, new order for HbA1C (blood test for diabetes determines the three-month average blood sugar level), next lab draw and Accuchecks twice a day. During an interview on 6/13/2023 at 8:10 AM, the ADON said she had been employed at the facility for 3 weeks. She said she was responsible for staffing the facility. She said she [NAME] formally been shown how to do an admission but said the nurses should have known to get blood sugar checks and parameters with insulin orders. She said the facility had been without a DON since 5/26/2023 but the Regional Nurse did come to the facility a couple times a week as needed. She said she was often called to work the floor and was doing the best she could. During a phone interview on 06/13/23 at 9:44 AM the Physician said, the facility should notify me if a blood sugar is below 80mg/dl or above 400mg/dl. Physician said he had not been notified of Resident #35's critical low blood sugar levels or her requesting to have Insulin dosage lowered. During an interview 06/13/23 at 10:03 AM LVN A said she had worked at the facility for a week. She had not seen the policy, Management of Hypoglycemia, or had she been trained on what to do when a resident had a critical lab value. She said the resident had a sliding scale while in the hospital but when orders were sent to the facility the orders were cut off and staff at the nursing facility were not aware of the sliding scale order. She said she had texted the Physician multiple times since yesterday when they became aware of no parameters, and the physician has not replied. LVN A said she had notified the Physician regarding Resident #35's scheduled Humulin 70/30 U-100 Insulin (NPH and regular Human) [OTC] suspension; 100 unit/ml (70-30); Amount to Administer: 20 units; subcutaneous twice a day, to see if the facility could get orders for parameters. LVN A notified the Physician that Resident #35 was requesting to get half of her insulin dosage when her blood sugar is low. During an interview 06/13/23 at 10:15 AM, the Treatment Nurse said she had worked at the facility for two years. She said if the facility was short staff she got pulled from doing treatments to work the floor. She said Resident # 35 was a very brittle diabetic and her blood sugars were hard to control. She said they do check the resident's blood sugar before giving her insulin. She said there were no physician's orders to check her blood sugar or parameters as to when to notify the physician. She said she had to give her orange juice and sugar before and a snack to bring her bloodsugar up. She said once the blood sugar was stable she did not think to notify the Physician. During an interview 06/13/23 at 10:34 AM the Interim Administrator said she expected her staff to notify the Physician of any change in the resident including low or high blood sugars. She said she expects her staff to be trained and have competency checks offs regarding Hypoglycemia or Hyperglycemia and to know when to notify the Physician. The Administrator said the resident could have gone into a coma if her BS is not controlled. She said she expects her staff to follow protocol for hypoglycemia, and the Regional Nurse was inservicing the staff on the policy today, she hopes to improve education for the staff. She said she will meet with families during care conference meetings and make sure they are doing everything they can to take care of the residents During an interview 06/13/23 at 10:47 AM Resident #35 said she didn't always get her snacks at bedtime, and that her blood sugar would drop. She said she could feel her blood sugar dropping sometimes and would call the nurse to come check it. She said the nurse would give her orange or apple juice with sugar and give her snacks to bring it up. She said she tried to keep snacks in her room. Resident #35 said she had tried to get the night nurse to only give her half of her insulin dosage because she kept dropping. The Administrator was notified on 06/13/23 at 3:00 PM that an Immediate Jeopardy situation had been identified due to the above failures. The facility's plan of removal was accepted on 6/14/2023 at 12:07 PM and included: Resident #35: The resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day with hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by the Clinical Resource Nurse and there were no signs or symptoms of hypo or hyperglycemia (low or high blood sugar). The Medical Doctor was consulted regarding current orders. The Medical Director has changed Resident #35's finger stick blood sugar; changed orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl; and Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED PRN 1 PRN 2, PRN 3. Action 1: Educate all nurses regarding the diabetic/managing hypoglycemia policy, physician notification, and change of condition (to include blood sugars out of range per the Physician's prescription below 80 and above 400). The licensed nursing staff will have an understanding to report out of range blood sugars to the physician through the above education and will obtain orders (if physician chooses to order) for finger stick blood sugars or parameters for reporting of abnormal blood sugars (per the Physician's preference below 80 and above 400). Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference. The facility will ensure competency of licensed nursing staff and ensure licensed nursing staff understand our management of hypoglycemia policy through the above education. The charge nurses will notify the doctor immediately if the blood sugar reading is above or below the parameters set by the residents' physician (the MD would like to be notified if blood sugar is outside 80-400), the charge nurse at that time will follow the MD's orders. The updated orders read as follows per the physician: Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Policy Managing Hypoglycemia has been updated to reflect follow provider orders/instructions for blood sugars under 80 and over 400 and/or to administer oral glucose/glucagon/call emergency services per policy. Orders will reflect PRN oral glucose/glucagon per policy and MD orders for residents receiving accuchecks. All nurses will be educated regarding the policy and policy changes. All current, new, and temporary (agency) nurses shall be educated regarding diabetic/managing hyperglycemia policy, physician notification with change of condition prior to working their next shift/first shift. Date of Completion 6/14/23 @ 12 PM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 2: Perform Blood Sampling- Capillary (Finger Stick) Competency competencies on all licensed nurses. All new and temporary (agency) nurses shall be checked off on Blood Sampling- Capillary (Finger Stick) Competency prior to working their next shift/first shift. Date of Completion: 6/14/2023 @ 12 PM Staff Responsible for Completion: Assistant Director of Nursing and/or Designee Action 3: Clinical Resource nurse performed an audit of all diabetic residents and ensured proper orders including: Finger Stick Blood Sugar orders and ensured proper insulin orders were in place. The Clinical Resource Nurse and the Medical Director reviewed all diabetic residents to ensure proper orders were in place. Special Instructions: Notify MD of results <80 or >400 has been added to all residents with finger stick blood sugar orders. Staff are aware of the parameters to report to the physician via education and orders inputted into the electronic medical record that reflect to notify the Medical Director if blood sugar is lower than 80 and higher than 400. The policy Managing Hypoglycemia has been updated to reflect the Physician's preference and physician's order/instruction upon notification of blood sugars lower than 80 and higher than 400. Date of Completion: 6/13/2023 Staff Responsible for Completion: Clinical Resource Nurse Action 4: Adhoc QAPI meeting performed with the Interim Administrator, Clinical Resource Nurse, and Medical Director to review the immediate jeopardy template, plan of removal, and diabetic residents. Date of Completion: 6/13/2023 Staff Responsible for Completion: Administrator and Clinical Resource Nurse These interventions were completed based on staff (Interim Administrator, ADON, Clinical Resource Nurse, and 4 LVNs (Treatment Nurse, Nurse A, Nurse G, Nurse H) on the morning and evening shift, were interviewed to ensure these interventions had been completed. Nursing staff were able to appropriately indicate they would follow the policy, Management of Hypoglycemia, the parameters of notification. A policy, Management of Hypoglycemia-Diboll Specific, updated 06/14/23 was reviewed by Surveyors. MANAGEMENT of HYPOGLYCEMIA: The following is a suggested protocol thaat should be implemented without the approval of the Medical Director and Director of Nursing. If there is already a protocol in place, disregard this and follow the existing approved protocol instead. 1. Classification of hyperglycemia: a. Level 1 hypoglycemia:blood glucose <80 mg/dl and >54 mg/dl b. Level 2 hypoglycemia: blood glucose is <54mg/dl: and c. Level 3 hypoglycemia: altered mental and or physical status requiring assistance for hypoglycemia. 2. For Level 1 hypoglycemia (<80mg/dl a. Give resident an oral form of rapidly absorbed glucose 1tube/15grams Notify the Physician immediately. b. Remain with the resident c. Recheck blood sugar in 15 minutes: 1. If blood glucose within establish reference range, pprovide the resident with a meal or snack. 2. If blood sugar is greater than established reference range (rebound Hyperglycemia) administer diabetic medication as ordered or 3. If blood sugar remains <80mg/dl, repeat oral glucose and notify physician for further orders. 3. For Level 2 hypoglycemia (<54mg/dl) a. Administer glucagon 1 vial/1mg I b. Notify the Physician Immediately c. Remain with the Resident d. Place resident in a comfortable and safe place (bed or chair) e. Monitor vital signs and f. Recheck blood glucose in 15 minutes (as Above) 4. If a resident has a Level 3 hypoglycemia and is unresponsive a. Call 911(in accordance with resident's advance directives b. Administer Glucagon 1 vial/1mg IM. c. Notify the Physician immediately d. Remain with the resident e. Place the resident in a comfortable and safe place (bed or chair); and f. Monitor vital signs During an interview on 6/14/2023 at 4:00 PM, the Interim Administrator said she had been at the facility since Monday 6/12/23. She said they had no DON, and the last DON left two weeks ago. She said her expectations were for the staff to be in-serviced on the Management of Diabetes. She said the Regional Nurse had audited the physician's orders on all resident to be ensure BS checks, and parameters to hold Insulin, and to notify the Physician of abnormal values, BS <80 and >400mg/dl had been implemented on all diabetics. On 6/14/2023, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Surveyors reviewed the inservices provided to staff on Diabetic protocol, Change in Condition, Physician notification, Management of hypoglycemia, and Blood Sampling. Surveyor reviewed the facility audit on all residents with diagnosis of Diabetes for BS checks and parameters of notification for abnormal blood sugars readings, Accucheck blood sugar checks on all residents to identify any high or low blood sugar readings. Reviewed training to be provided to all new and temporary agency nurses. Nurses shall be educated regarding diabetes managing hyperglycemia policy physician notification with change of condition prior to working their next shift/first shift. Post Test. Record review of Resident #35: Resident's Physician has been notified by the Clinical Resource Nurse regarding the out of range (lower than 80) blood sugar levels that occurred on 05/17/23 and 05/21/23. New orders received for labs to include hemoglobin A1C, one time order, and Accuchecks twice a day and hold parameters to hold insulin if blood sugar is less than 100. On 06/13/23 Resident #35 was assessed by Clinical Resource Nurse, no signs or symptoms of hypo or hyperglycemia. (low or high blood sugar). Medical Doctor was consult regarding current orders. Medical Director has changed Resident #35's finger stick blood sugar, change orders to: Accucheks twice a day and hold parameters to hold insulin if blood sugar is less than 100mg/dl. Blood Sugar prn for signs or symptoms of hyperglycemia or hypoglycemia. Special Instructions to notify MD of results < 80 or > 400 AS NEEDED During interviews on 06/14/23 at 10:15 AM with 4 LVNs LVN A Treatment Nurse, LVN G, LVN H (per phone conversation) on the morning and evening shifts on 6/14/23, revealed all employees indicated understanding of the policy, Management of Hypoglycemia, and parameters for holding Insulin if BS below 100mg/dl. On 6/14/2023 at 5:00 PM, the Interim Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of the potential for more than minimal harm with a scope identified as isolated,due to the facility's need to evaluate the corrective actions. The facility continued to monitor and in-service staff to ensure all were in-serviced on the management of hypoglycemia protocol.