Burnett Medical Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Surveyor interviewed Licensed Practical Nurse (LPN) C regarding blood sugar monitoring and insulin administration. LPN C stated that if a provider does not have specific orders for communicating blood sugars, the facility uses standing orders to notify provider when blood sugar is lower than 70. LPN C was not certain when to communicate elevated blood sugars but believed it should be above 400. LPN C stated that insulin or hypoglycemic meds should always be administered per the provider orders and any dose changes would be communicated by the provider and then documented in a progress note. Surveyor asked LPN C is it was an acceptable practice to administer an insulin dose different than ordered if the resident requests to do so. LPN C stated, no, that the provider would need to be contacted prior to administering a different dose than ordered.On 10/28/25 at 3:47 PM, Surveyor interviewed Director of Nursing (DON) B regarding Resident R1's diabetic care. DON B stated the provider should be contacted per orders regarding blood sugars and medication refusals. Surveyor asked DON B if it was an acceptable practice for nurses to administer medications outside of order parameters. DON B stated the nurses should not be administering medications differently than the provider ordered. Surveyor asked if she was aware that multiple doses of insulin and glucose tabs were administered to Resident R1 differently than ordered. DON B stated this was something that she had become aware of and was working on re-educating staff on following provider orders.On 10/28/25 at 3:58 PM, Surveyor interviewed LPN E asking about blood sugar monitoring, documentation, insulin administration, and physician notification. LPN E stated a blood sugar over 400, would call the physician. If Resident R1 was given any insulin, Resident R1 would drop. There was nothing in Resident R1's MAR to state when to call the physician. If the blood glucose meter would read ‘high', staff would document in the [DATE REDACTED] and would retake the blood sugar in 10 minutes and give insulin and would be down to 350. If Resident R1 was low, staff would give 2 glucose tabs and would check blood sugar in 10 to 15 minutes later. LPN E stated she did not notify the physician when Resident R1's blood sugar was out of range. Resident R1 would request the amount of insulin Resident R1 wanted and would then administer that amount. LPN E stated the physician was not notified when insulin was not given as ordered. LPN E stated did not receive education at the facility for when blood sugars are out range and when to notify the physician. On 10/29/25 at 10:36 AM, Surveyor interviewed Interim Chief Executive Officer (CEO) D regarding Resident R1's care. CEO D stated there is no question that the expectation is for nurses to follow the provider's orders. Staff would be expected to communicate with the provider if a resident refuses medications or with changes in blood sugars, especially with a brittle diabetic like Resident R1. CEO D stated the facility can definitely do better in this area.

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