cms_TN: 4422
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4422 | CREEKSIDE CENTER FOR REHABILITATION AND HEALING | 445516 | 306 W DUE WEST AVENUE | MADISON | TN | 37115 | 2016-10-24 | 157 | K | 1 | 0 | CT4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, medical record review, and interview, the facility failed to notify the physician of residents with a blood glucose greater than 400 for 5 (Resident #2, #6,#5, #7, #8) of 12 residents reviewed for Diabetes Mellitus. These failures placed all diabetic residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death or a resident). The Administrator (NHA) was informed of the Immediate Jeopardy on 10/24/16 at 3:15 PM in the Conference Room. The findings included: Review of facility policy, Change in Resident's Condition or Status, undated, revealed, .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Nursing services will notify the resident's attending physician when .there is a significant change in the resident's physical, mental or psychosocial status .there is a need to alter the resident's treatment .Deemed necessary or appropriate in the best interest of the resident . Review of facility policy, Diabetes, Nursing Care of the Adult Diabetes Mellitus Resident, undated revealed, .The physician should be notified when the blood sugar falls above his/her specified blood sugar range and/or above 400 mg/dL (milligrams per deciliter). The Medical Director of the facility is the physician of record for all the residents. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].ACCUCHECKS (finger stick for blood sugar) BEFORE BOLUS FEEDINGS AND SSI (sliding scale insulin) AS FOLLOWS: 0-59 = CALL MD (Medical Doctor) .351-400 = 10u .NOTIFY MD AND RECHECK IN 15 MINUTES . Medical record review of the 6/2016 Medication Administration Record [REDACTED] 591 on 6/4 at 7:30 AM 432 on 6/6 at 6:00 AM 401 on 6/7 at 12:00 AM High on 6/9 at 12:00 PM 456 on 6/12 at 6:00 AM 429 on 6/18 at 6:00 AM Medical record review revealed no notification of the MD or Nurse Practitioner (NP) regarding the elevated blood sugars. Medical record review of the 7/16 MAR indicated [REDACTED] 564 on 7/1 at 6:00 AM 441 on 7/1 at 12:00 PM 503 on 7/6 at 12:00 AM 489 on 7/9 at 12:00 PM 518 on 7/10 at 12:00 AM 511 on 7/10 at 12:00 PM 405 on 7/12 at 12:00 AM 466 on 7/25 at 6:00 AM 459 on 7/27 at 12:00 AM 436 on 7/31 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 8/16 MAR indicated [REDACTED] 475 on 8/1 at 12:00 AM 492 on 8/7 at 6:00 PM 456 on 8/20 at 6:00 PM 432 on 8/21 at 6:00 PM 493 on 8/25 at 6:00 PM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars. Medical record review of the 9/16 MAR indicated [REDACTED] 423 on 9/3 at 12:00 PM 487 on 9/4 at 6:00 PM 47 on 9/7 at 12:00 PM 452 on 9/10 at 12:00 PM 482 on 9/16 at 12:00 AM 434 on 9/17 at 6:00 AM 491 on 9/17 at 12:00 PM 501 on 9/22 at 12:00 PM 560 on 9/23 at 6:00 AM 474 on 9/23 at 12:00 PM 420 on 9/26 at 12:00 AM Medical record review revealed no notification of the MD or NP regarding the elevated blood sugars or the low blood sugar on 9/7/16. Telephone interview with Licensed Practical Nurse (LPN) #5 on 10/18/16 at 4:00 PM revealed, I did not call the Doctor when the sugar was 560 on 9/23/16. Interview with LPN #6 on 10/19/16 at 7:15 AM, in the conference room confirmed Resident #2's blood sugar was 47 on 9/7/16 and she failed to notify the physician. Medical record review of the 10/2016 MAR indicated [REDACTED]. Medical record review revealed no notification of the MD or NP regarding the elevated blood sugar. Interview with the Director of Nursing (DON) on 10/19/16 at 4:05 PM, in the conference room confirmed the facility policy was to notify the physician if a blood sugar was less than 60 or greater than 400. Continued interview with the DON confirmed the facility failed to follow the policy and notify the physician of the elevated blood sugars for Resident #2. Medical record review revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed the order stated if the resident's blood glucose was greater than 400 the nurse was to administer 10 units of insulin and notify the physician. Medical record review of a History and Physical from the hospital dated 9/14/16 revealed Resident #6 was admitted for a blood sugar which was .measurable high . Continued review revealed the blood glucose in the Emergency Department was 500 and significant ketosis was present. Medical record review of the blood glucose monitoring sheets and the Medication Administration Record [REDACTED] a. 9/20/16 blood glucose 593 at 9:00 PM b. 9/24/16 blood glucose 405 at 9:00 PM c. 9/29/16 blood glucose 421 at 1:00 PM d. 9/29/16 blood glucose 423 at 5:00 PM e. 10/4/16 blood glucose 405 at 6:15 PM Continued review revealed no documentation the physician was notified of any of these abnormal blood glucose results. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's admission orders [REDACTED]. If BS (blood sugar) > (greater than) 400 notify MD and recheck in 15 minutes . Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed no documentation the physician was notified of the abnormal blood glucose result. Medical record review revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of physician's admission orders [REDACTED]. Continued review revealed if the blood glucose was greater than 400 the nurse was to notify the physician and recheck the blood glucose in 15 minutes. Medical record review of the blood glucose monitoring record and the MAR indicated [REDACTED]. Continued review revealed there was no documentation the physician was notified of the abnormal blood glucose result. Interview with the Administrator and new Director of Nursing (DON) on 10/24/16 at 11:15 AM, in the Conference Room revealed they had been working on this tag since the last survey with continued education about notification. Continued interview revealed the DON stated she could not say why nurses were still not documenting physician notification. Interview with Nurse Practitioner (NP) #2 on 10/24/16 at 12:20 PM in the conference room revealed she had never been notified of any medications being administered late. Continued interview revealed NP #2 stated if a blood glucose was greater than 400 she would expect the nurse to recheck in 15 to 30 minutes and notify her if it was still elevated. | 2019-10-01 |