Astoria Skilled Nursing: Resident Death Triggers Immediate Jeopardy Citation
CANTON, OH - A diabetic nursing home resident died after staff failed to check on him for more than six hours overnight, leaving him unmonitored despite dangerously high blood sugar levels that ultimately proved fatal.
Federal inspectors determined Astoria Skilled Nursing and Rehabilitation faced immediate jeopardy to resident safety after the March incident involving a resident with Huntington's disease and insulin-dependent diabetes. The resident was found unresponsive in his wheelchair at 4:30 AM with blood sugar levels exceeding 500 mg/dl - more than five times the normal range.
Critical Care Failures Led to Death
The 42-year-old resident required constant monitoring due to multiple serious medical conditions including Huntington's disease, diabetes requiring insulin injections, seizure disorder, and significant mobility impairments. His care plan specifically required checks every two hours for incontinence care and monitoring for diabetic complications.
On the evening before his death, Licensed Practical Nurse (LPN) #433 administered the resident's routine medications at approximately 10:00 PM, including 40 units of long-acting insulin. At that time, his blood glucose measured 400 mg/dl - already in the dangerous hyperglycemic range. Normal blood glucose levels typically range from 70-100 mg/dl.
Despite the elevated reading, no follow-up glucose checks were performed. The resident remained alone in his wheelchair throughout the night until State Tested Nursing Assistant #501 discovered him unresponsive during early morning rounds.
Medical Significance of Hyperglycemia
Blood glucose levels of 400 mg/dl represent severe hyperglycemia requiring immediate medical intervention. At this level, the body begins breaking down fat for energy, producing ketones that can lead to diabetic ketoacidosis - a life-threatening emergency.
When left untreated, severe hyperglycemia causes dehydration as the kidneys attempt to eliminate excess glucose through frequent urination. This process leads to electrolyte imbalances affecting heart rhythm and brain function. The resident's blood sugar had climbed to 509 mg/dl by the time emergency responders arrived, reaching 607 mg/dl at the hospital - levels that can cause coma and death.
Proper diabetes management protocols require blood glucose monitoring every 6 hours for residents on insulin, with immediate physician notification for readings above 300 mg/dl. The facility's own policy mandated monitoring for hyperglycemia symptoms including flushed skin, nausea, abdominal pain, and altered breathing patterns - all potentially preventable with appropriate oversight.
Staffing Shortages Compromised Care
Investigation revealed critical staffing deficiencies on the night of the incident. The facility operated with only three nursing assistants covering both wings instead of the standard five, creating dangerous coverage gaps.
STNA #542 worked alone on the East wing from 7:00 PM until 10:30 PM, while STNA #505 handled the entire west wing by herself. The resident requiring care lived on the west wing but received no attention after the nurse's 10:00 PM medication administration.
Multiple staff members confirmed they were aware the resident remained in his wheelchair but assumed others would provide necessary care. The breakdown in communication proved fatal when STNA #501, who arrived to assist at 9:15 PM, was never informed about the resident's elevated blood sugar or need for positioning assistance.
Emergency Response and Hospital Course
When discovered unresponsive at 4:30 AM, the resident showed signs of severe medical distress. Emergency responders found him slumped in his wheelchair with dark fluid emanating from his nose and mouth - consistent with aspiration of stomach contents, a common complication of diabetic emergencies.
Facility staff initiated cardiopulmonary resuscitation while awaiting emergency medical services. The local fire department arrived at 4:46 AM and continued advanced life support measures, successfully restoring the resident's pulse before transport.
Despite intensive care treatment at the hospital, the resident's condition deteriorated. The prolonged hyperglycemic episode had caused irreversible damage to his brain and other vital organs. He passed away several days later, with the diabetic emergency identified as the precipitating factor in his death.
Pattern of Sexual Abuse Incidents
Federal inspectors also discovered multiple incidents of resident-to-resident sexual abuse that administrators failed to properly investigate or report to state authorities. The violations involved a male resident with severe cognitive impairment who engaged in inappropriate sexual behavior toward vulnerable female residents.
Staff witnessed the resident sexually assaulting another cognitively impaired resident in a bathroom, but facility leadership dismissed the incidents as coincidental bathroom encounters rather than predatory behavior. The perpetrator was supposed to receive constant one-on-one supervision but was frequently left unattended.
Medication Safety Lapses During Discharge
Additional violations included unsafe discharge practices for residents requiring controlled substances. One resident with ADHD and chronic pain was discharged without adequate supplies of prescribed Adderall and hydrocodone to last until her follow-up appointment four days later.
The facility's policy prohibited sending narcotic medications home with Medicare residents, regardless of medical necessity. This practice violated federal requirements ensuring safe transitions and continuity of care, potentially triggering withdrawal symptoms or medical emergencies.
Kitchen Sanitation Hazards
Inspectors found extensive sanitation problems in the facility's kitchen that posed infection risks to all residents receiving meals. A large hole in the wall near the dishwashing area harbored significant gnat infestations, while the walk-in refrigerator contained moldy shelving and food debris on floors.
Water damage had destroyed sections of wall tile and drywall, creating breeding grounds for insects and bacteria. The compromised food service environment violated federal standards requiring clean, pest-free meal preparation areas.
Immediate Corrective Actions Required
The Centers for Medicare & Medicaid Services removed the immediate jeopardy designation only after the facility implemented comprehensive reforms including mandatory diabetes monitoring protocols, enhanced staffing requirements, and systematic care plan audits.
New procedures require blood glucose checks for all diabetic residents five times weekly, with automatic physician notification for readings above established parameters. Staff received additional training on recognizing diabetic emergencies and implementing appropriate interventions.
The facility also enhanced its incident reporting system to ensure proper documentation and investigation of all allegations of abuse or neglect. These systemic changes aim to prevent future tragedies like the preventable death that triggered federal intervention.
The case demonstrates how multiple system failures - inadequate staffing, poor clinical oversight, and insufficient monitoring protocols - can combine with devastating consequences for vulnerable nursing home residents requiring complex medical care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Astoria Skilled Nursing and Rehabilitation from 2024-06-12 including all violations, facility responses, and corrective action plans.
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