The incident at Hollywood Premier Healthcare Center on August 30 left the resident vulnerable to dangerous blood sugar swings that could have caused serious complications, according to federal inspectors who cited the facility for failing to meet professional care standards.
Resident 2, admitted just five days earlier with diabetes and severe cognitive impairment, yanked out his nasogastric tube around 3 p.m. Staff tried unsuccessfully to reinsert the thin feeding tube that delivered nutrition directly to his stomach. His primary physician ordered a transfer to the hospital for tube replacement.
The ambulance didn't arrive until 9:30 p.m.
During those critical hours, nursing staff never checked the resident's blood sugar levels despite his diabetes diagnosis and extended fasting period. Licensed vocational nurse LVN 1 told inspectors that blood sugar monitoring "is important to ensure Resident 2's blood sugar level was not low or high."
Another nurse, LVN 2, acknowledged she failed to obtain blood sugar readings and admitted the resident "had the potential to have hyperglycemia or hypoglycemia" during the prolonged period without food.
The resident had been admitted on August 25 with multiple conditions including diabetes and difficulty swallowing. His care plan, established the next day, specifically identified him as at risk for both dangerously high and low blood sugar levels. The plan set target blood sugar ranges between 65 and 115 millimoles per liter and included interventions to "monitor blood sugar as ordered."
Federal inspectors found the facility's own policies required blood sugar monitoring when diabetic residents are fasting before medical procedures or experiencing acute illness. The resident's feeding tube removal and subsequent fasting clearly fell under these guidelines.
The 83-year-old man required total assistance with basic activities including oral hygiene, toileting, showering and dressing. His severe cognitive impairment meant he couldn't advocate for himself or communicate symptoms of blood sugar problems.
Diabetic patients face serious risks when blood sugar levels swing too high or too low, particularly during extended fasting periods. Hypoglycemia can cause confusion, seizures, loss of consciousness and death. Hyperglycemia can lead to diabetic coma and other life-threatening complications.
The facility's change of condition report documented the feeding tube incident at 3:21 p.m., noting staff had attempted reinsertion without success. The physician's transfer order came promptly, but the six-and-a-half-hour delay before hospital transport created an extended period of vulnerability.
LVN 1 confirmed during interviews that the resident "had nothing to eat" during the entire waiting period. Standard diabetic care protocols call for frequent blood sugar monitoring during such circumstances, especially for patients with cognitive impairment who cannot report symptoms.
The facility's diabetes care policy, reviewed in January, explicitly states staff should monitor blood glucose "if the individual is fasting before a medical procedure, has returned to the facility after a significant absence or has an acute infection or illness."
Both nurses interviewed acknowledged the monitoring failure. LVN 2 stated directly that she "did not obtain Resident 2's blood sugar level" despite the extended fasting period and diabetes diagnosis.
Inspectors classified the violation as having potential for actual harm, though they found minimal harm actually occurred. The citation affects quality standards that nursing facilities must meet to participate in Medicare and Medicaid programs.
The resident's case illustrates gaps in diabetes management at the facility, where staff failed to follow their own established protocols during a medical emergency. His severe cognitive impairment made him entirely dependent on nursing staff to recognize and respond to potential complications.
Federal inspectors completed their review on September 15, documenting the August incident as part of a complaint investigation. The facility must submit a plan of correction addressing how it will ensure proper diabetes monitoring during future medical emergencies and extended fasting periods.
The resident spent those vulnerable hours without the basic blood sugar monitoring that could have detected dangerous changes in his condition, leaving him at risk for serious complications that proper nursing care should have prevented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hollywood Premier Healthcare Center from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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