Souris Valley Care Center

F-F760 is considered past noncompliance. The facility implemented the corrective actions to ensure the deficient practice does not recur by:

* The facility conducted an investigation on 08/19/24 with interviews of staff that determined the cause of the incident. Nursing staff failed to administer long-acting insulin as ordered due to a transcription error.

* Provided 1 to 1 education on transcribing orders after the incident and on 08/19/24 with all nursing staff on insulin administration, blood glucose monitoring, and notification of change policy. Those not in attendance received education prior to start of their shift.

* Suspended the nurse involved until the investigation was completed.

* Reviewed medical records of all residents receiving insulin to ensure insulin administered at the appropriate time.

* Implemented a secondary observer of management staff to review all new admission orders.

* On 08/19/24 began audits on new admission orders, insulin administration, blood glucose monitoring, physician notification, and documentation of blood glucose parameters.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 2 355109