Failure to Notify Physician of Critically High Blood Glucose and Perform Ordered Monitoring
Summary
The deficiency involves the facility’s failure to immediately notify the physician when a resident’s blood glucose (BG) levels exceeded ordered parameters and to consistently perform ordered BG monitoring. An older female resident with type 2 DM with hyperglycemia, early-onset Alzheimer’s disease, hypertension, and a vesicointestinal fistula was admitted with physician orders for BG monitoring before meals and at bedtime, with instructions to notify the provider if BG was less than 60 mg/dL or greater than 400 mg/dL. Review of the order summary and admitting physician orders confirmed these parameters. However, record review showed multiple BG readings well above 400 mg/dL over several days without documented physician notification, and there was no evidence that bedtime BG checks were performed as ordered. Specifically, the resident’s record showed BG values of 512 mg/dL on one day, 482 mg/dL on the next day, 459 mg/dL on a later day, and 492 mg/dL on another day, all documented without any corresponding evidence that the physician was notified, despite the explicit order to notify for BG values greater than 400 mg/dL. The medication administration record and BG logs also showed no documented nighttime BG checks, even though the orders required monitoring before meals and at bedtime. The resident’s care plan identified insulin therapy and BG monitoring with goals for BG within normal limits and interventions including monitoring, documenting, and reporting adverse effects of insulin therapy and following hypo/hyperglycemia protocols, but the actual documentation did not reflect adherence to these monitoring and notification requirements. Interviews with facility staff and external PACE providers further described inconsistent communication and incomplete implementation of ordered treatments. The NP from PACE stated she was not notified that the resident’s BG had been over 400 mg/dL and that, upon later review, insulin and BG monitoring orders had been provided but were not implemented as ordered by the facility. A PACE RN reported that he was notified of elevated BG and gave instructions for additional sliding scale insulin and close monitoring, and that long-acting insulin should have continued, but there was no documentation in the facility record to support these communications or new orders. Facility nurses described elevated BG readings in the 400–500 mg/dL range, sometimes unreadable on the glucometer, ongoing use of sliding scale insulin, delays or gaps in admission order processing, and uncertainty about whether antibiotics ordered were administered. The resident was ultimately transferred to the hospital with hyperglycemia and UTI and was admitted to the ICU for DKA and septic shock. The facility’s own policy on blood glucose monitoring required following physician notification parameters when results were outside ordered ranges, but the documented practice for this resident did not meet those requirements, leading surveyors to identify an Immediate Jeopardy situation related to failure to notify the physician of out-of-parameter BG results and failure to carry out ordered BG monitoring. Additional interviews with leadership and other staff highlighted that medication reconciliation and admission review processes were inconsistent and that there was no standardized daily review of medications or BG monitoring for accuracy and completeness. The ADON and DON acknowledged that medication pass audits were not done daily, that there was no consistent daily process to review medications, and that communication with external providers such as PACE was often inconsistent. The DON and Medical Director described expectations that urgent situations be evaluated immediately and that orders be implemented without delay, but also acknowledged that residents with worsening conditions were sometimes transferred to the hospital rather than having earlier interventions. The MDS nurse stated that she did not recall seeing documentation regarding antibiotic therapy or BG monitoring for this resident and that follow-up on such treatments depended on nursing processes. The PACE NP later stated that prophylactic antibiotics and insulin management had been ordered but not administered, and that the resident’s decline, including DKA and sepsis, was attributed in part to missed medications and lack of timely intervention. These documented failures in BG monitoring, physician notification, and implementation of ordered treatments formed the basis of the cited deficiency.
Removal Plan
- Conduct mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtain verbal and written confirmation of understanding; implement ongoing competency checks; ensure policies are readily available from the CNO/ACNO; incorporate training and written competencies for new hires upon hire.
- Review Resident #2’s current hospitalization status with the hospital and confirm ICU admission for DKA and septic shock; confirm resident did not return to the facility.
- Hold nurse meetings with all nursing staff who cared for Resident #2 to review specific failures (missing bedtime BG checks, failure to notify provider of BG >400, failure to administer continuous glucose monitoring device, failure to communicate about unavailable supplies).
- Provide mandatory re-education for all licensed nursing staff (RNs/LPNs) emphasizing: obtaining BG readings exactly as ordered; immediate provider notification when results are outside parameters; immediate notification to physician/CNO/ACNO when ordered supplies/equipment are unavailable; and clarifying unclear or unimplementable orders prior to implementation.
- Establish a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes in condition, out-of-parameter lab/glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-service RNs/LVNs on the protocol.
- Implement a redundant notification system requiring that when any BG result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time, person contacted, and response received; in-service RNs/LVNs on the system.
- Conduct a facility-wide review to identify residents at risk for similar failures related to physician notification, BG monitoring, or implementation of orders.
- Review all current residents to identify those with active BG monitoring orders.
- Complete a comprehensive chart audit of residents with BG monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely documented provider notification; report identified issues to physicians and obtain clarifying or new orders as needed; initiate continued daily monitoring by CNO/ACNO/nurse manager.
- Conduct a Root Cause Analysis (RCA) including staff interviews and fishbone analysis to identify underlying causes of the IJ event.
- Revise the Blood Glucose Monitoring Policy to require immediate physician notification for out-of-parameter BG results and to require documentation of the exact time of the out-of-parameter result, exact time of provider notification, name of person contacted, and provider response or orders received; educate staff on the revised policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Timely Notify Physician for Worsening Cough: A resident with CHF, edema, and other cardiac diagnoses developed a persistent worsening cough with SOB and severe discomfort after being placed on comfort care and do-not-hospitalize orders. Staff gave PRN morphine and cough syrup with little relief, but the RN and DON knew about the decline and relied on faxing the MD rather than timely direct notification. The care plan did not reflect the comfort care orders or guidance for managing a change in condition.
A resident with severe cognitive impairment, diabetes, and an existing heel PI developed a new ischemic/necrotic change to the right first toe, but the facility did not notify the PCP or wound care provider as ordered. The toe change was documented on a skin audit and later observed as black on the top of the toe, yet the wound team was not updated and the wound later measured larger than when first identified.
The facility failed to notify the provider of a significant orthostatic BP drop for one resident and failed to notify the provider after two blood glucose readings over 400 mg/dL for another resident. One resident had intact cognition, antipsychotic use, and an order for monthly orthostatic BP checks, but the EMR showed a systolic drop from lying to standing without provider notification. Another resident with type 1 DM and severe cognitive impairment had orders to update the provider for BG >400 mg/dL, yet EMR review showed readings of 498 mg/dL and 449 mg/dL with no documented provider notification.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
A resident with moderate cognitive impairment and multiple chronic conditions sustained a skin tear to the lower shin that was documented by an LVN, who attempted but failed to reach the resident’s POA and did not leave a voicemail, assuming the treatment nurse would notify the family. The treatment nurse documented the wound, obtained MD orders, and provided treatment but did not contact the family, citing a facility practice that charge nurses handle family notification. The resident’s representative reported learning of the injury only upon visiting and seeing the wound, and leadership acknowledged that both the physician and the representative were not notified as required by the facility’s significant change in condition policy.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
Failure to Timely Notify Physician for Worsening Cough
Penalty
Summary
The facility failed to timely notify the physician when a resident with intact cognition and diagnoses including edema, heart failure, hypertension, premature ventricular contractions, and tricuspid regurgitation developed a worsening cough that did not improve. The resident’s quarterly MDS showed she required moderate assistance with transfers, dressing, and hygiene. After a clinic visit, she returned with orders for comfort care only, including do not hospitalize, stopping metolazone, increasing Lasix to 80 mg twice daily, and discontinuing labs per family request. The physician’s note described chronic fluid retention, weight gain, generalized edema, decreased strength, occasional shortness of breath, and a persistent cough, with the family choosing comfort care after discussion of prognosis and limited benefit of further hospitalization. Nursing notes showed the resident continued to cough chronically and was not resting well. Staff administered PRN morphine in an attempt to relieve discomfort from the cough related to fluid overload, but the medication was ineffective and the resident reported severe pain rated 8 out of 10 with no relief from the cough or discomfort. The care plan addressed diuretic therapy and monitoring for side effects, but it did not include the comfort care orders, the do not hospitalize direction, discontinuation of labs, or instructions for maintaining comfort if the resident’s condition changed. Interviews with the RN and DON confirmed they were aware of the resident’s coughing and believed it was related to fluid retention. The DON stated the facility had received the order not to send the resident to the hospital and agreed the care plan should have included comfort measures. The record also showed staff faxed the physician for guidance but did not receive a response, and the DON stated they could not call the doctor during clinic hours and had been advised to fax instead. The physician was not contacted until the on-call MD later ordered increased PRN morphine frequency for pain, shortness of breath, or cough.
Failure to Notify PCP of New Toe Skin Alteration
Penalty
Summary
The facility failed to ensure the PCP and wound care provider were notified of a change in condition for a resident with severely impaired cognition, diabetes mellitus, and non-Alzheimer's dementia who was dependent on staff for toileting, bed mobility, transfers, and lower body dressing. The resident was admitted with an unstageable pressure injury to the left heel and had a care plan focused on that wound, but the care plan did not include any toe concerns. A weekly skin audit later identified ischemic tissue on the tip of the right first toe, measuring 1.2 cm by 0.9 cm, and a nursing progress note documented that an on-call senior care NP was notified and instructed staff to continue monitoring and update the PCP wound nurse on the next business day. The required update was not completed. The consultant wound care NP visit on 4/16/26 documented the left heel wound as healed and noted no new skin issues were reported, and the NP was not informed about the new right first toe skin alteration first observed on 4/4/26. When the wound provider later evaluated the toe, it was documented as a non-pressure wound of unknown duration, full thickness, and at least greater than 14 days old, with measurements of 1.2 cm by 1.8 cm. The wound had increased in width by 0.9 cm since it was first measured, and new orders were issued for Betadine and off-loading. During observation, the resident's right first toe was exposed and black on the top, and staff described it as a bruise of unknown duration. Interviews confirmed the facility did not complete the ordered update to the PCP wound care provider and did not maintain consistent monitoring of the necrotic toe. The DON stated the facility should have updated the PCP or wound provider as identified in the on-call order and documented the change in the medical record, and the wound care NP's medical liaison confirmed their service was not updated on the new skin alteration.
Failure to Notify Provider of Orthostatic BP Drop and Critical Hyperglycemia
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident with orthostatic hypotension. R5’s quarterly MDS showed intact cognition, antipsychotic use, and substantial to maximum assistance with ADLs. R5 had an order for monthly orthostatic blood pressure monitoring because of antipsychotic use, and the 4/18/26 vital signs record showed a blood pressure of 122/72 lying, 118/71 sitting, and 101/62 standing, reflecting a systolic drop greater than 20 mmHg from lying to standing. The EMR did not show that the physician was notified of this orthostatic blood pressure drop. During interviews, RN-D and RN-C stated staff should notify the provider for a 20-point orthostatic drop, and RN-C stated the 4/18/26 drop had not been reported. The facility also failed to notify the physician after two hyperglycemic blood glucose readings greater than 400 mg/dL for another resident. R68’s quarterly MDS showed severely impaired cognition and substantial to maximum assistance with ADLs, and diagnoses included type 1 diabetes mellitus with other diabetic neurological complications and other frontotemporal neurocognitive disorder. R68 had an order for accuchecks three times daily with meals and to update the provider if blood sugar was less than 90 mg/dL or greater than 400 mg/dL. The EMR showed blood glucose readings of 498.0 mg/dL on 3/26/26 and 449.0 mg/dL on 4/20/26, but there was no evidence the provider was notified for either reading. RN-B and RN-A stated staff should notify the provider for elevated blood sugar readings over 400 mg/dL, and RN-A could not locate documentation of provider notification for the two events.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and representative of a significant change in condition following a skin tear. The resident was an older male with anxiety disorder, hypertension, and benign prostatic hyperplasia, admitted with a care plan that included treatment for a skin tear to the left lateral shin. An admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Facility incident and accident reports identified a skin tear event for this resident, and physician telephone orders were obtained to cleanse the affected area and apply dressings daily. A progress note documented that an LVN observed a skin tear/abrasion to the left lower shin and attempted to call the resident’s daughter/POA, but there was no answer and no voicemail left. The treatment nurse’s subsequent progress note documented that she was notified of the skin tear and that the wound measured 8x6 cm, and she obtained and implemented MD orders, but did not contact the family, stating that per facility culture the charge nurse was responsible for family notification. The resident’s representative reported she was never contacted by nursing staff and only learned of the skin tear when she visited and saw the injury. Interviews with LVN A confirmed she attempted to call but did not leave a voicemail and believed the treatment nurse would call the family, while the treatment nurse confirmed she did not contact the family. The DON acknowledged that the resident’s representative should have been notified per the facility’s significant change in condition policy, which states that the resident representative will be notified of a change in condition. The Administrator stated that the physician should have been notified but was not, while staff prioritized providing care to the resident at that time.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.