HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice was evidenced by:
1) failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 8 (#R23-R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed (see findings in A0395);
2) failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 26 (#R2-#R20, #R23-#R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed (see findings in A0395);
3) failure of the nursing staff to monitor blood glucose results or document provider notifications for out of range blood glucose results per provider orders in 1 (#1) of 3 (#1-#3) patients reviewed (see findings in A0398); and
4) failure of the nursing staff to administer Patient #1's medications per physician order (see findings in A0405).

Based on record review and interviews, the hospital failed to ensure the patients right to make informed decisions regarding his or her care. This deficient practice was evidenced by failure to notify and allow the patient representative to make decisions related to care after evidence of neglect was identified involving Patient #1.
Findings:

Review of hospital policy number RTS-01, titled "Patient Rights Louisiana," last revised 09/01/2025, revealed in part: "PURPOSE: To ensure that all patients are aware of their rights while being treated at this facility and to provide guidance to the program staff regarding the method for ensuring patient rights are respected and the method for restricting a patient's rights if deemed necessary. PROCEDURE: 4. If the patient is cognitively and/or physically unable to sign and comprehend this information about their rights, the patient's guardian or a family member will be so informed and will sign them as legally appropriate; or if the patient is disoriented or in a state that impairs cognition at the time of entry, he/she is informed of his/her rights at an appropriate time during care, treatment, and services. Treatment: You have the right be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instated on the patient's behalf will be respected in accordance law and regulations. You have the right to have medications prescribed by a practitioner and only administered under their order. You have the right to be informed about the outcomes/unanticipated occurrences in order to participate in current and future healthcare decisions."

Review of Patient #1's medical record revealed that Patient #1 was admitted with a diagnosis Psychosis, behavioral disturbance, and cognitive disorder. Patient #1 had a history of Dementia, Hypertension, Diabetes Mellitus type 2, Coronary Artery Disease, Hyperlipidemia, and Hypokalemia.

Review of Patient #1's consents revealed that Patient #1 was unable to sign and participate in treatment plan due to cognitive impairment.

Review of self-report revealed in part that Patient #1 was involved in an incident of gross neglect related to S10LPN fabricating medical documentation and failing to carry out provider orders.

Review of Patient #1's medical record revealed in part that Patient #1 received the incorrect insulin twice on 07/08/2025. Further review of Patient #1's medical record revealed that the nurse failed to monitor the patients BG and administer insulin per provider orders.

In an interview on 08/06/2025 at 10:40 AM, S2ADM confirmed that the self-report documented that Patient #1's family was not notified of the alleged neglect.

In an interview on 08/07/2025 at 12:17 PM, S1DON confirmed that the family of Patient #1 was not notified of the unanticipated outcomes and occurrences involving Patient #1.

Based on observation and interview, the hospital failed to ensure each patient's right to receive care in a safe setting. The deficient practice is evidenced by:
1) leaving an unlocked medication cart unattended in a patient care area posing a potential risk for injury; and
2) failure to notify the provider of a critical lab result per hospital policy for Patient #1.
Findings:

1) Leaving an unlocked medication cart unattended in a patient care area posing a potential risk for injury.
During a tour on 08/06/2025, S5LPN was observed with the medication cart in Room #a preparing medications for patient medication pass. There were 8 patients sitting in the Room #a watching the television. S5LPN was observed walking away from the medication cart and entering Room #b to administer medications. Further observation revealed that the medication cart was not locked while it was left unattended which contained medications and needles which patients could access.

In an interview on 08/06/2025 at 11:47 AM, S1DON, S3DOQ, and S4ADN confirmed the above mentioned findings. S1DON further confirmed that there were no other staff in Room #a with the 8 patients when S5LPN walked away from the unlocked medication cart.

In an interview on 08/06/2025 at 11:50 AM, S5LPN confirmed that she left the medication cart unlocked when she walked away from it. S5LPN further confirmed that she should have locked the cart before leaving it unattended in the patient care area.

2) Failure to notify the provider of a critical lab result per hospital policy for Patient #1.

A review of hospital policy number NSG-67, titled "Protocols for Critical Lab Values," last revised 10/01/2024, revealed in part: "POLICY: All critical laboratory test results require prompt notification to care providers including the read back process when appropriate to ensure patient safety. PROCEDURE: 2. The nursing staff will receive report/notification of all critical labs from lab vendor. 3. The Physician/Non-Physician Practitioner (NPP) will be notified within 30 minutes of the nurse receiving the critical lab value. 8. Critical Lab monitoring and communication is incorporated into the Performance Improvement Program."

Review of Patient #1's medical record revealed the following nursing notes in part:
07/08/2025 at 11:00 AM- called and notified critical lab (blood sugar) of 409. Documented by S8RN.
07/08/2025 at 12:00 PM- Checked Patient #1's blood glucose at 11:45 AM, too high to read. 14 units of Humulin R given per Humulin R sliding scale. Notified RN. Documented by S9LPN.
07/08/2025 at 12:09 PM- Notified NP of critical blood glucose lab result from labcorp and recheck of current blood glucose which was too high to read on Accu-check monitor. Per NP check patient blood sugar every 2 hours and give sliding scale insulin. Documented by S8RN.
Further review of Patient #1's medical record failed to reveal that the critical lab result was reported to the provider within 30 minutes per policy.

In an interview on 08/07/2025 at 11:21 AM, S1DON confirmed that the nurse did not notify the provider of the critical lab for a glucose of 409 for Patient #1 within 30 minutes per hospital policy.

Based on record review and interview, the hospital failed to measure, analyze and track all adverse patient events. The deficient practice is evidenced by failing to provide documentation of preventative actions that were implemented to educate staff related to insulin administration and following provider orders.
Findings:

Review of hospital policy number QAPI-004, titled "Incident Reporting," last revised 08/01/2024, revealed in part: "PURPOSE: To document any potential or adverse incident within the facility or on the facility grounds/property/vehicle, with the facts available at the time, recorded by persons involved, either in the incident or in the discovery of the incident. Information to Provide in the Incident Report: 1. The Incident Report shall be limited to factual statements (who, what, where, and when) related to the patient safety incident and any interventions take to reduce the risk of future incidents and promote safety. Incident Reporting Investigation: 2. Each department Director is responsible for reviewing incidents that occur in their area, investigating and completing follow-up. 4. Assess staff members and processes involved in events for training, education, or process improvement. 7. The Quality Director and Hospital Administrator are mandatory reviewers of all incidents. 9. The Quality Director shall track and trend all incident types. 10. All aggregated data should be brought forward to the appropriate committee for performance improvement activities."

Review of hospital policy number MM-01, titled "Medications," last revised 12/01/2024, revealed in part: "POLICY: The hospital will ensure that all medications related to the patient in patient stay are ordered, dispensed, labeled, stored, transcribed, administered, and documented in the medical record in accordance with Federal and State Law and industry best practices. Evaluation of Medication Management System: DON: Collects and analyses data on performance of the medication management system. Compares data over time to identify risk points, levels of performance, patterns, trends and variations. Research literature and external sources for new technologies and best practices. PI Committee Process: Based on aforementioned actions identifies opportunities to improve and recommends same. Continues to evaluate actions to confirm implemented opportunity resulted in improvement. Take additional action when improvements are not achieved or not sustained. Undertakes an annual evaluation at minimum, of medication management system."

Review of the hospital incident log revealed in part:
07/08/2025: Patient #1, Incident Category: Medication Variance

Review of the incident report involving Patient #1 revealed in part:
Date/Time: 07/08/2025 at 2:00 PM - Medication Variance
Provide a brief factual description of the incident:
14 units of Humulin R given at 12:00 PM instead of 18 units of Humalog
14 units of Humulin R given at 2:00 PM. MD states that he only wanted it one time not every 2 hours.
Related Causes and Factors: Transcription error
Actions taken post incident: MD notified, Supervisor notified, Treatment/evaluation conducted, accuchecks ordered every hour.
Follow Up/Resolution (QD): Blank
Follow Up/Resolution (DON): Blank
Follow Up/Resolution (CEO): Blank
Administrator/CEO Reviewed: No
Quality Director Reviewed: No

Review of Patient #1's medical record revealed in part the following nursing notes:
07/08/2025 at 12:05 PM- Checked patients CBG at 11:45. CBG too high to read. 14 units of Humulin R given per Humulin R sliding scale. Notified RN. Documented as a late entry by S9LPN on 07/10/2025 at 11:06 AM.
07/08/2025 at 12:09 PM- Notified NP of critical blood glucose lab result from labcorp and recheck of current blood glucose which was too high to read on the Accucheck monitor. Per NP check patient blood sugar every 2 hours and give sliding scale insulin. Documented by S8RN on 07/10/2025 at 10:43 AM.
07/08/2025 at 2:00 PM- Check patients CBG at 2:00 PM. CBG too high to read. Administered 14 units of Humulin R insulin. Notified NP. NP clarified that the order for sliding scale insulin was not meant to be given every 2 hours, only for the initial accucheck at 11:45 PM. New orders noted to recheck CBG every hour and notify NP of readings. Documented by S9LPN on 07/10/2025 at 11:14 AM.
07/08/2025 at 3:00 PM- Notified S1DON that incorrect insulin was given. Rechecked CBG at 3:00 PM. CBG too high to read. Notified MD of incorrect medication given and new accucheck reading for 3:00 PM. No new orders at this time. Documented by S9LPN on 07/10/2025 at 11:21 AM.
07/08/2025 at 4:00 PM- Rechecked CBG at 4:00 PM. Accucheck 517. Notified NP. No new orders noted. Documented by S9LPN on 07/10/2025 at 11:28 AM.

Review of Patient #1's physician orders revealed in part the following:
Order date 07/07/2025- Discontinue date 07/16/2025:
-Insulin Lispro (Humalog) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 18 units, call MD or NPP and recheck CBG in 30 minutes and continue with sliding scale. If Capillary Blood Glucose still greater than 400 after 30 minutes, call MD or NPP for further orders. SLIDING SCALE: 61-99= 0 units; from 100-150=3 units; from 151-200= 6units; from 201-250= 9 units; from 251-300= 12 units; from 301-350= 15; from 351-400= 18 units; greater than 400 call MD/NP= 18 units.

Further review of Patient #1's medical record failed to reveal orders for Humulin R entered by the provider.

Review of Patient #1's MAR for 07/08/2025 revealed in part:
11:30 AM: Humalog- documented as not given. Reason- Other reason/pharmacy consult. Documented by S9LPN.
The MAR failed to reveal that Patient #1 received 2 doses of Humulin R (28 units total).

During an interview on 08/07/2025 at 12:17 PM, S1DON verified that she was made aware of the medication error when Patient #1 received the wrong insulin, stating the provider "refused" to enter an order for the Humulin R that was administered by S9LPN. S1DON stated that a verbal order was taken by S8RN from the provider after receiving the critical lab glucose result to obtain BG every 2 hours. S1DON also verified that S9LPN did not scan the patient armband and check the medication against the MAR prior to administration. S1DON confirmed the provider did not change the order for the Humalog sliding scale insulin. S1DON further confirmed at the time of the incident Patient #1 had no order for Humulin R on the patient MAR.

Based on observations, record reviews, and interviews, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by:
1) failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 8 (#R23-R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed; and
2) failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 26 (#R2-#R20, #R23-#R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed.
Findings:

Review of hospital policy number CS-23, titled "Level of Observations," last revised 03/01/2023, revealed in part: "PURPOSE: To provide staff with a framework for monitoring patients to ensure safety. Observations should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety. Observation Levels: Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. PROCEDURE: 3. Staff members utilize the close observation form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15 minute increments on the form to indicate the patient was observed. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form."

1) Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 8 (#R23-R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed.

Observations during a walk-through on 08/06/2025 from 11:25 AM-12:00 PM revealed that the last RN observations were performed at 9:00 AM on Observation Check Sheet/Graphic Flowsheet. Further review of the Observation Check Sheet/Graphic Flowsheet failed to reveal that RN observations were performed every 2 hours per hospital policy from 9:15 AM-11:30 AM on Patients #R23-#R30.

In an interview during the tour, S1DON confirmed the above mentioned findings.

2) Failure of the Registered Nurse to supervise staff to ensure timely observation rounds were performed for 26 (#R2-#R20, #R23-#R30) of 38 (#R1-#R38) Patient Observation Check Sheets reviewed.

Observations during a walk-through on 08/06/2025 revealed the following on Unit B:

S6MHT was assigned to Patients #R23-#R25. Review of Patient #R23-#R25 Observation Check Sheet/Graphic Flowsheets failed to reveal that Q15 minute observations were performed at 11:15 AM or 11:30 AM for Patient #R23-#R25.

In an interview on 08/06/2025 at 11:34 AM, S1DON confirmed the above mentioned findings.

S7MHT was assigned to Patients #R26-#R30. Review of Patient #R26-#R30 Observation Check Sheet/Graphic Flowsheets revealed that S7MHT had pre-signed the 11:45 AM observation round for all 5 patients she was observing. Further review of S7MHT's observation flowsheets revealed that Patient #R30 was not in Room #d with the other patients S7MHT was observing.

In an interview on 08/06/2025 at 11:38 AM, S1DON confirmed that the Observation Check Sheet/Graphic Flowsheets were pre-signed for the 11:45 AM observation round on Patients #R26-#R30. S7MHT verified that Patient #R30 was in Room #e, which could not be visualized from where she was sitting.

Observations during a walk-through on 08/06/2025 revealed the following on Unit A:

Review of Patient #R2-#R20's Observation Check Sheet/Graphic Flowsheets for Unit A failed to reveal that Q15 minute observations were performed at 7:00 AM, 7:15 AM, 7:30 AM, or 7:45 AM.
Further review of Patient #R2's observation flowsheet also failed to reveal that Q15 minute observations were performed at 11:00 AM.
Further review of Patient #R3's observation flowsheet also failed to reveal that Q15 minute observations were performed at 11:30 AM or 11:45 AM.

In an interview on 08/06/2025 at 11:55 AM, S1DON confirmed the above mentioned findings.

Based on record review and interview, the Director of Nursing failed to ensure nursing staff adhered to the policies and procedures of the hospital. This deficient practice was evidenced by failure of the nursing staff to monitor blood glucose results or document provider notifications for out of range blood glucose results per provider orders in 1 (#1) of 3 (#1-#3) patients reviewed.
Findings:

Review of hospital policy number MM-17, titled "Insulin administration," last revision 08/01/2025, revealed in part: "PURPOSE: To provide guidelines for the safe administration of insulin and the correct dose of insulin based on the measurement of capillary blood glucose levels (CBG). To provide guidelines for the monitoring and treatment of high blood sugar/hyperglycemia and low blood sugar/hypoglycemia. POLICY: Insulin is used to control hyperglycemia in patients with diabetes mellitus. Insulin injections will be administered in accordance with the following procedures by licensed nursing staff. Each hospital's sliding scale insulin therapy will be approved by its medical staff and will be utilized in giving the licensed nurse direction for management in controlling capillary blood glucose levels of diabetic patients. Accurate glycemic control using a safe and effective sliding scale insulin therapy can reduce risks for complications of diabetes mellitus and the patient's length of stay. Indications: Treatment of hyperglycemia and hypoglycemia will consist of orders contained within each hospital's sliding scale insulin protocol."

Review of Patient #1's medical record revealed that Patient #1 was admitted on 06/28/2025-07/02/2025 and sent to ED for evaluation of Hyperglycemia and Hyperkalemia. Patient #1 was readmitted on 07/07/2025. Admit diagnosis Psychosis, behavioral disturbance, and cognitive disorder. Patient #1 had a history of Dementia, Hypertension, Diabetes Mellitus type 2, Coronary Artery Disease, Hyperlipidemia, and Hypokalemia. Patient #1 was discharged on 07/16/2025.

Review of Patient #1's provider orders for 06/28/2025-07/02/2025 revealed in part the following:
06/28/2025: Finger stick Blood Glucose before meals and at Bedtime
Sliding Scale orders revealed in part:
06/28/2025: Insulin Regular (Humulin R) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 14 units, call MD or NPP and recheck CBG in 1 hour. If Capillary Blood Glucose still greater than 400 after 1 hour, call MD or NPP for further orders. Discontinue date 07/04/2025.

Review of Blood Glucose values on 06/28/2025-07/02/2025 revealed in part the following:
06/29/2025 at 11:58 AM- BG=498 (Not rechecked within 1 hour per provider order. BG rechecked 2 hours later. No provider notification)
06/29/2025 at 2:01 PM- BG= 357
06/29/2025 at 9:13 PM- BG=400 (Not rechecked within 1 hour per provider order. BG rechecked 8 hours later. No provider notification)
06/30/2025 at 5:30 AM- BG=45
06/30/2025 at 5:30 AM- BG=97
06/30/2025 at 11:03 PM- BG=508 (Not rechecked within 1 hour per provider order. BG rechecked 5.5 hours later)
07/01/2025 at 4:35 AM- BG=58 (Not rechecked within 10 minutes per provider order. BG rechecked 7.5 hours later. No provider notification)
07/01/2025 at 11:58 AM- BG=356
07/02/2025 at 11:30 AM- BG=586 (Not rechecked within 1 hour per provider order. Patient #1 sent to ED for evaluation on 07/02/2025 at 3:40 PM)

Review of Patient #1's provider orders for 07/07/2025-07/16/2025 revealed in part the following:
07/07/2025: Finger stick Blood Glucose before meals and at Bedtime
07/07/2025: Humalog Sliding Scale- Blood glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. Blood glucose greater than 400, administer 18 units, recheck BG after 30 minutes and continue with sliding scale. If capillary BG still greater than 400 after 30 minutes, call MD or NPP for further orders. Discontinued at discharge.
07/08/2025 at 12:33 PM: Finger stick Blood Glucose every 2 hours.
07/08/2025 at 4:12 PM: Finger stick Blood Glucose every 1 hour.
07/08/2025 at 11:29 PM: Finger stick Blood Glucose every 2 hours.
07/09/2025 at 6:15 AM: Finger stick Blood Glucose before meals and at Bedtime, with sliding scale insulin orders for Blood glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. Blood glucose greater than 400, administer 18 units, recheck BG after 30 minutes and continue with sliding scale. If capillary BG still greater than 400 after 30 minutes, call MD or NPP for further orders. Discontinued at discharge.

Review of Blood Glucose values on 07/07/2025-07/16/2025 revealed in part the following:
07/07/2025 at 5:00 PM- Patient #1 readmitted to facility.
07/07/2025 at 9:44 PM- BG=144 documented by S10LPN
07/07/2025 at 9:53 PM- BG= documented as "Refused/Unable" by S10LPN (No provider notification)
07/08/2025 at 4:35 AM- ordered blood work drawn by lab corp
07/08/2025 at 6:58 AM- BG= 104 documented by S10LPN
07/08/2025 at 10:32 AM- BG= 104 documented by S9LPN
07/08/2025 at 11:00 AM- critical lab glucose result of 409 called to hospital.
07/08/2025 at 11:45 AM- BG= HI (Not rechecked within 30 minutes per provider order. BG rechecked 2 hours later)
07/08/2025 at 2:00 PM- BG=HI (provider order for BG Q2 hours initiated)
07/08/2025 at 4:13 PM- BG=517 (provider order for BG Q1 hour initiated)
07/08/2025 at 5:03 PM- BG=317
07/09/2025 at 3:28 PM- BG=598 (Not rechecked within 30 minutes per provider order. BG rechecked 5 hours later)
07/09/2025 at 8:13 PM- BG=411 (Not rechecked within 30 minutes per provider order. BG rechecked 3 hours later)
07/09/2025 at 11:09 PM- BG=145
07/10/2025 at 12:23 PM- BG=468 (Not rechecked within 30 minutes per provider order. BG rechecked 4 hours later. No provider notification)
07/10/2025 at 4:21 PM- BG=145
07/13/2025 at 11:43 AM- BG=400 (Not rechecked within 30 minutes per provider order. BG rechecked 10 hours later. No provider notification)
07/13/2025 at 9:30 PM- BG=366

In an interview, during medical record review, on 08/07/2025 from 9:12 AM-12:30 PM, S1DON confirmed the above mentioned findings. S1DON further confirmed that the nursing staff did not monitor Patient #1's blood glucose per provider orders or notify the provider for out of range blood glucose results.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to the physician's orders. The deficient practice is evidenced by failure of the nursing staff to administer Patient #1's medications per physician order.
Findings:

Review of hospital policy number MM-01, titled "Medications," last revised 12/01/2024, revealed in part: "POLICY: The hospital will ensure that all medications related to the patient in patient stay are ordered, dispensed, labeled, stored, transcribed, administered, and documented in the medical record in accordance with Federal and State Law and industry best practices. MEDICATION ADMINISTRATION: Before administering a medication, the licensed independent practitioner or qualified individual administering the medication does the following: Verifies that the medication selected for administration is the correct one based on the medication order, prescriber instructions, MAR and product label. Verifies that there is no contraindication for administering the medication. Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Advises the patient or, if appropriate, the patient's family about any potential clinically significant adverse reaction or other concerns about administering a new medication. Reports any untoward or side effects to the physician/NPP, and documents all communication, findings, and status in the medical record and completes a medication variance form. DOCUMENTATION: All medications shall be documented on the patient's Medication Administration Record (MAR) immediately after administration. RN/LVN/LPN: 2. If a dose of scheduled medication is withheld or not given, circles the hour of administration for the medication in question and initials next to circled time, or appropriately indicates the withheld or not given medication in the EMR, as applicable. Records a full explanation in the integrated progress notes and/or MAR. Physician must be notified, and documentation entered into the progress notes of physician/NPP notification. (Medication variance must be completed and submitted to nursing leadership)."

Review of Patient #1's medical record revealed that Patient #1 was admitted on 06/28/2025-07/02/2025 and 7/07/2025-07/16/2025. Admit diagnosis Psychosis, behavioral disturbance, and cognitive disorder. Patient #1 had a history of Dementia, Hypertension, Diabetes Mellitus type 2, Coronary Artery Disease, Hyperlipidemia, and Hypokalemia. Patient #1 was discharged on 07/16/2025.

Review of Patient #1's physician orders revealed in part the following:
Order date 06/28/2025- Discontinue date 07/04/2025:
-Insulin Glargine (Lantus) 30 units subcutaneously at Bedtime. Indication: type 1 diabetes mellitus.
-Insulin Regular (Humulin R) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 14 units, call MD or NPP and recheck CBG in 1 hour. If Capillary Blood Glucose still greater than 400 after 1 hour, call MD or NPP for further orders. SLIDING SCALE: 61-200= 0 units; from 201-250=3 units; from 251-300= 6units; from 301-350= 9 units; from 351-400= 12 units; greater than 400 call MD/NP=14 units.

Review of Patient #1's MAR revealed in part the following:
07/01/2025 9:19 PM: Humulin R- documented as not given. BG=241. Reason- Parameter Not Met. Patient accepted 30 units Lantus at HS. Held Sliding Scale. Documented by S11LPN.
Further review of Patient #1's medical record failed to reveal that the Humulin R was administered per physician order or that the provider was notified.

In an interview on 08/07/2025 at 9:56 AM, S1DON confirmed the Humulin R was not administered per physician order. S1DON also confirmed there was no documented evidence that the provider was notified that the medication was not given.

Review of Patient #1's physician orders revealed in part the following:
Order date 07/07/2025- Discontinue date 07/11/2025:
-Insulin Glargine (Lantus) 15 units subcutaneously twice a day. Indication: type 2 diabetes mellitus.

Review of Patient #1's MAR revealed in part the following:
07/07/2025 9:53 PM: Lantus 15 units- documented as not given. BG=refused. Reason- Refused. Documented by S10LPN.
07/10/2025 9:33 PM: Lantus 15 units- documented as not given. BG=124. Reason- Parameter not met. Documented by S11LPN.
Further review of Patient #1's medical record failed to reveal that the Lantus was administered per physician order or that the provider was notified.

In an interview on 08/07/2025 at 11:45 AM, S1DON confirmed the Lantus was not administered per physician order. S1DON also confirmed there was no documented evidence that the provider was notified that the medication was not given. S1DON verified that the order for Lantus does not have parameters.

Review of Patient #1's physician orders revealed in part the following:
Order date 07/07/2025- Discontinue date 07/16/2025:
-Insulin Lispro (Humalog) subcutaneously before meals and at bedtime - SEE SLIDING SCALE- Capillary Blood Glucose less than or equal to 60, give orange juice orally (if allergic to orange juice, give Glucagon 1mg IM). Recheck Blood glucose in 10 minutes. If BG still less than or equal to 60, call MD immediately. Capillary Blood Glucose greater than 400, give 18 units, call MD or NPP and recheck CBG in 30 minutes and continue with sliding scale. If Capillary Blood Glucose still greater than 400 after 30 minutes, call MD or NPP for further orders. SLIDING SCALE: 61-99= 0 units; from 100-150=3 units; from 151-200= 6units; from 201-250= 9 units; from 251-300= 12 units; from 301-350= 15; from 351-400= 18 units; greater than 400 call MD/NP= 18 units.

Review of Patient #1's MAR revealed in part the following:
07/07/2025 9:53 PM: Humalog- documented as not given. BG=144. Reason- Refused. Documented by S10LPN.
Further review failed to reveal documented evidence that the provider was notified.

07/08/2025 6:30 AM: Humalog- documented as not given. BG=104. Reason- Medication parameter not met. Documented by S10LPN.
07/10/2025 6:26 AM: Humalog- documented as not given. BG=126. Reason- Medication parameter not met. Documented by S11LPN.
07/10/2025 10:31 PM: Humalog- documented as not given. BG=124. Reason- Medication parameter not met. Documented by S11LPN.
07/11/2025 5:57 AM: Humalog- documented as not given. BG=127. Reason- Medication parameter not met. Documented by S11LPN.
07/15/2025 9:32 PM: Humalog- documented as not given. BG=122. Reason- Medication parameter not met. Documented by S11LPN.
Review of sliding scale revealed that Patient #1 should have received 3 units of Humalog. Further review failed to reveal the Humalog was administered per sliding scale physician order or that the provider was notified.

07/15/2025 6:30 AM: Humalog- documented as 3 units given. BG=202. Documented by S11LPN.
Review of sliding scale revealed that Patient #1 should have received 9 units of Humalog. Further review failed to reveal the Humalog was administered per sliding scale physician order.

In an interview during medical record review, on 08/07/2025 from 9:12 AM-12:30 PM, S1DON confirmed the above mentioned findings. S1DON verified that the nursing staff were not following the sliding scale parameters or administering medication per provider order.

Review of Patient #1's physician orders revealed in part the following:
Order date 07/11/2025- Discontinue date 07/16/2025:
-Insulin Glargine (Lantus) 15 units subcutaneously at bedtime. Indication: type 2 diabetes mellitus.

Review of Patient #1's MAR revealed in part the following:
07/15/2025 9:32 PM: Lantus 15 units- documented as not given. BG=122. Reason- Medication parameter not met, CBG does not meet parameters. Documented by S11LPN.
Further review of Patient #1's medical record failed to reveal that the Lantus was administered per physician order or that the provider was notified.

In an interview on 08/07/2025 at 12:15 PM, S1DON confirmed the Lantus was not administered per physician order. S1DON also confirmed there was no documented evidence that the provider was notified that the medication was not given. S1DON verified that the order for Lantus does not have parameters.

Based on observation and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by failing to store patient nutritional supplies in a sanitary condition.
Findings:

Observations during a tour of North campus on 08/06/2025 revealed the following expired nutritional supplies in the refrigerator in Room #c:
Skim Milk, quantity 2, expiration date 08/03/2025
Glucerna, quantity 3, expiration date 07/15/2025

In an interview on 08/06/2025 at 11:58 AM by S3DOQ and S4ADN confirmed the above mentioned findings.

Based on record review and interview, the facility failed to ensure each patient had an individualized, comprehensive treatment plan based on an inventory of the patient's strengths and disabilities. This deficient practice is evidenced by the facility failing to include the patient's ordered precautions in the nursing care plan for 1 (#1) of 3 (#1-#3) patient care plans reviewed for the inclusion of all medical and psychological needs of a patient.
Findings:

Review of Patient #1s medical record revealed Patient #1 was admitted on 06/28/2025. Review of Patient #1's provider orders revealed orders for violence, fall, and elopement precautions. Review of Patient #1's nursing care plan failed to reveal risk for elopement as part of the care plan.

Further review of Patient #1's medical record revealed Patient #1 was re-admitted on 07/07/2025. Review of Patient #1's provider orders revealed orders for violence, fall, and elopement precautions. Review of Patient #1's nursing care plan failed to reveal risk for violence as part of the care plan.

In an interview on 08/07/2025 at 11:42 AM, S1DON confirmed the above mentioned findings. S1DON also confirmed that provider precaution orders should be included in the nursing care plan for each patient.