South Mountain Post Acute

The facility failed to ensure proper monitoring for 1 out of 3 dialysis residents (#1).

The facility failed to ensure proper monitoring for 1 out of 3 dialysis residents (#1).

Based on clinical record review, staff interviews and policy reviews, the facility failed to ensure that 1 of 3 sampled residents (#2) received long-acting insulin per hospital discharge orders upon admission. The deficient practice could result in uncontrolled blood sugar levels. Findings include: Resident #2 was admitted on February 13, 2024 with diagnoses that included type 2 diabetes mellitus, Parkinson's disease, and dementia. Review of final orders/discharge instructions from the referring hospital, dated February 13, 2024 (prior to admission), included that the patient was to continue insulin Glargine (insulin glargine/Lantus) 15 units twice daily without any changes. Review of physician's orders dated February 13th- 19th,2024 revealed no evidence of physician orders regarding Insulin Glargine despite being listed on the hospital final orders/discharge instructions. An order summery dated February 13, 2024 revealed all medication orders were reviewed by the attending physician and he concurred with the present plan of care and discharge plan. Further review of physician orders dated February 14, 2024 included Glucose monitoring with instructions to notify the provider if glucose is less than 70 or more than 400 mg/dL. A Care Plan dated February 14, 2024, revealed a focus of Diabetes Mellitus with interventions that included diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, monitor/document/report to MD PRN (as needed) signs and symptoms of hyperglycemia. An Admission MDS (Minimum Data Set) assessment dated February 17, 2024 included that the resident had a BIMS (Brief Interview for Mental Status) score of 2, which indicated severe cognitive impairment. The assessment indicated the resident had clear speech, was not oriented to time or place and at times appeared anxious, fearful and wandered. On February 18, 2024 the resident's blood glucose test results were 572.0 mg/dL. A progress note dated February 18, 2024 revealed that the resident's blood sugar was 572.0 mg/dL at 1:06pm and the provider was notified. However, there was no evidence regarding the provider's response including any medication changes, related to the increase in blood glucose levels. On February 18, 2024 at 4:41pm, the resident's blood glucose level was 219.0 mg/dL. A nursing progress note dated February 18, 2024 revealed blood glucose level at baseline and well controlled, despite evidence of blood glucose fluctuations during the day. A review of the resident's blood glucose results on February 19 through February 20, 2024 revealed: February 19, 2024 - 8:32 am- 229.0 mg/dL - 11:37 am- 271.0 mg/dL - 5:01 pm- 333.0 mg/dL - 10:03 pm- 321.0 mg/dL February 20, 2024 - 8:03 am- 337.0 mg/dL - 8:33 am- 337.0 mg/dL - 12:03 pm-337.0 mg/dL - 4:45 pm -357.0 mg/dL - 7:08 pm- 335.0 mg/dL A FNP (Family Nurse Practitioner) progress note dated February 20, 2024 indicated that, the resident's blood glucose remains elevated and to start a low do

Based on clinical record review, staff interviews and policy reviews, the facility failed to ensure that 1 of 3 sampled residents (#2) received long-acting insulin per hospital discharge orders upon admission. Findings include: Resident #2 was admitted on February 13, 2024 with diagnoses that included type 2 diabetes mellitus, Parkinson's disease, and dementia. Review of final orders/discharge instructions from the referring hospital, dated February 13, 2024 (prior to admission), included that the patient was to continue insulin Glargine (insulin glargine/Lantus) 15 units twice daily without any changes. Review of physician's orders dated February 13th- 19th,2024 revealed no evidence of physician orders regarding Insulin Glargine despite being listed on the hospital final orders/discharge instructions. An order summery dated February 13, 2024 revealed all medication orders were reviewed by the attending physician and he concurred with the present plan of care and discharge plan. Further review of physician orders dated February 14, 2024 included Glucose monitoring with instructions to notify the provider if glucose is less than 70 or more than 400 mg/dL. A Care Plan dated February 14, 2024, revealed a focus of Diabetes Mellitus with interventions that included diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, monitor/document/report to MD PRN (as needed) signs and symptoms of hyperglycemia. An Admission MDS (Minimum Data Set) assessment dated February 17, 2024 included that the resident had a BIMS (Brief Interview for Mental Status) score of 2, which indicated severe cognitive impairment. The assessment indicated the resident had clear speech, was not oriented to time or place and at times appeared anxious, fearful and wandered. On February 18, 2024 the resident's blood glucose test results were 572.0 mg/dL. A progress note dated February 18, 2024 revealed that the resident's blood sugar was 572.0 mg/dL at 1:06pm and the provider was notified. However, there was no evidence regarding the provider's response including any medication changes, related to the increase in blood glucose levels. On February 18, 2024 at 4:41pm, the resident's blood glucose level was 219.0 mg/dL. A nursing progress note dated February 18, 2024 revealed blood glucose level at baseline and well controlled, despite evidence of blood glucose fluctuations during the day. A review of the resident's blood glucose results on February 19 through February 20, 2024 revealed: February 19, 2024 - 8:32 am- 229.0 mg/dL - 11:37 am- 271.0 mg/dL - 5:01 pm- 333.0 mg/dL - 10:03 pm- 321.0 mg/dL February 20, 2024 - 8:03 am- 337.0 mg/dL - 8:33 am- 337.0 mg/dL - 12:03 pm-337.0 mg/dL - 4:45 pm -357.0 mg/dL - 7:08 pm- 335.0 mg/dL A FNP (Family Nurse Practitioner) progress note dated February 20, 2024 indicated that, the resident's blood glucose remains elevated and to start a low dose of Glargine/Lantus 5 units at bed time. A Physician Order dated, Febr