| 195 |
FLEETWOOD REHABILITATION AND HEALTHCARE CENTER |
425018 |
200 ANNE DRIVE |
EASLEY |
SC |
29640 |
2017-10-06 |
157 |
D |
1 |
1 |
NTTE11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the physician of significant changes in blood glucose levels for 1 of 5 sampled residents reviewed for unnecessary medication. The physician was not notified of multiple blood sugar results greater than 400 as ordered for Resident #2. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/6/17 revealed 6/29/2017 physician's orders [REDACTED].= 3 units; 251-300 = 5 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 13 units. Notify provider; 451-500 = 15 units subcutaneously before a meal and at bedtime for diabetes. Notify provider if BG >400 and Review of the 7/17 Medication Administration Record [REDACTED]= 433 at 1630h(ou)rs and 429 at 2100hrs, 7/3 = 454 at 1630hrs, 542 at 2100hrs, 7/7 = 4[AGE] at 2100hrs, 7/13 = 426 at 2100, 7/15 = 406 at 2100, 7/17 = 499 at 2100hrs, 7/20 = 426 at 1630hrs and 458 at 2100hrs, 7/21 = 415 at 0700hr, 7/22 = 414 at 2100hrs, 7/28 = 422 at 2100, and 7/29 = 458 at 2100. Continuing review of the 8/17 MARs revealed that Resident #2's blood glucose was 405 on 8/1, 413 on 8/3 at 1630hrs, 402 on 8/4, 432 on 8/8 at 2100hrs, 448 on 8/9 at 1630hrs, 478 on 8/12 at 2100hrs, 427 on 8/17, 415 on 8/18 at 1630hrs, 414 on 8/24 at 2100hrs, and 416 on 8/29 at 1630hrs. Review of 9/17 MARs revealed that Resident #2's blood glucose was 407 on 9/4 at 2100hrs, 427 on 9/6 at 1630hrs, 402 on 9/8, 401 on 9/9, 525 on 9/12/17, 410 on 9/18, 504 on 9/25 at 2100hrs, and 468 on 9/26 at 0700hrs. Review of Nurse's Notes on 10/05/2017 at 9:45 AM for the months of July, August, and September, 2017 revealed no documentation regarding notifying the physician of blood sugar results greater than 400. During an interview on 10/05/2017 at 9:09 AM, Licensed Practical Nurse (LPN) #4 could not locate any documentation on either the computerized records or the resident's medical record that stated the physician had been notified of any blood sugar results of greater than 400. LPN #4 spoke to the Director of Nursing (DON) on the same day at approximately 9:15 AM regarding locating documentation to show that the physician had been notified at any time. The DON was unable to find any evidence of physician notification. S/he stated that the facility was aware of the problem and it had provided group in-service/counseling on 9/20/17 but the problem had not been resolved. The DON verified the above findings on 10/05/2017 9:47 AM. |
2020-09-01 |