The resident, identified as Resident B, was supposed to receive physician notification whenever blood glucose levels reached 351 or higher. Instead, dangerous readings went unreported for weeks.
On June 24, the resident's blood sugar hit 484. Nobody called the doctor.
On June 25, it reached 351. No notification.
The pattern continued through late June and into July. On June 26, the reading was 400. On June 27, it spiked three times: 391 at 6 a.m., 515 at 11 a.m., and 462 at 4 p.m. On June 28, morning and afternoon readings of 483 and 368 also went unreported.
A July 11 reading of 375 similarly failed to trigger the required physician notification.
The Director of Nursing confirmed to inspectors that there was "no documentation that indicated the physician had been notified of the blood glucose results of 351 and over."
The medication failures extended beyond blood sugar monitoring. Resident B was prescribed ceftriaxone sodium, an antibiotic for an abdominal wall abscess, to be administered once daily for seven days starting June 17. Staff marked the medication as "not administered" on June 18 and only gave it for six of the required seven days.
A second antibiotic, cephalexin for a urinary tract infection, was missed entirely on July 6 at 5 p.m. Staff also failed to check the resident's blood glucose at 4 p.m. on July 6, missing both the monitoring and any needed insulin administration.
The facility's problems extended to a dementia resident whose aggressive behaviors were documented but never addressed with a proper care plan. Resident G displayed what staff described as "exit seeking behavior," cursing at staff, attempting to hit nurses, and trying to leave the facility through emergency doors.
On June 25, the resident "attempted several times to hit the staff with his fist" while nursing assistants tried to help with toileting. Staff noted he was "yelling, cursing, and calling the staff names."
Two days later, he "began to yell obscenities towards the staff and told them to get out" when nurses attempted to assist him. He "attempted to enter other residents' rooms" while staff provided "one on one redirection."
The facility documented dozens of behavioral episodes throughout June and July but never created a care plan to address them. On some days, staff recorded four separate behavioral incidents. On others, they documented episodes but noted "no interventions provided" or "no interventions documented."
When anti-anxiety medication lorazepam was administered on July 5 and July 10, there was no documentation that staff had attempted any non-pharmacological interventions first, as required by physician orders.
The Social Service Director acknowledged to inspectors that "there was no care plan with interventions for the resident's behaviors and there had been no social service involvement with behavior modification."
A third resident with severe cognitive impairment fell beside his bed on July 22. He told staff he "just wanted to see what the world looked like from the bottom up" and denied falling. The investigation failed to determine when he was last observed before the fall or identify the root cause.
The Director of Nursing told inspectors he "thought the resident had rolled out of bed" but acknowledged the investigation "had not included the last time the resident had been observed prior to the fall or the root cause of the fall."
The facility's fall prevention policy contained no post-fall protocol, despite the resident being assessed as high risk for falls upon admission.
Additional violations included posting outdated nurse staffing information that incorrectly included assisted living staff members, and wound care nurses failing to use required enhanced barrier precautions during pressure ulcer treatments.
The Administrator admitted to inspectors that they "just realized on August 5 they were included on the postings" regarding the incorrect staffing information that had been displayed for months.
During wound care observations, an LPN incorrectly told inspectors that enhanced barrier precautions "only had to be implemented if the wounds had drainage," contradicting the facility's own policy requiring precautions for any skin opening requiring a dressing.
The inspection, conducted in response to multiple complaints, documented systematic failures across medication administration, behavior management, fall prevention, and infection control that put vulnerable residents at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ignite Medical Resort Dyer LLC from 2024-08-08 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Ignite Medical Resort Dyer LLC
- Browse all IN nursing home inspections