ALBEMARLE, NC – FORREST OAKES HEALTHCARE CENTER

Based on record reviews and staff interviews, the facility failed to obtain and administer an intermediate acting insulin (NPH) and a rapid-acting insulin ([MEDICATION(S)]) for 1 of 3 newly admitted insulin dependent residents (Resident #2) resulting in hospitalization for six days with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

During an interview on 2/25/20 at 4:35 p.m., the Executive Director stated while receiving in-room therapy on the morning of 11/10/20, the therapist noticed a change in Resident #2’s interactions and called for the nurse who took his vital signs. The resident’s blood sugars read HI (glucometer maximum was 600). The nurse informed the nurse practitioner who ordered STAT laboratory work up. The laboratory notified the facility of the resident’s blood sugars were at the critical high value of 1452. The physician was notified and the resident was sent to the hospital. She stated because the resident’s blood sugars were at such a critical high value, she and the acting Director of Nursing (DON) made the decision to investigate what caused the resident’s blood sugars to rise so high and if the facility could have prevented the occurrence. Their findings included: the resident was admitted to the facility on [DATE] (Saturday); unless notified, the pharmacy did not make weekend deliveries; and the facility did not have the resident’s type of insulin in-house. She stated there were two nurses on duty on 11/7/20 and 11/8/20. Nurse #1 worked first and second shifts and Nurse #2 worked third shift both days. The Executive Director stated the nurses on duty failed to follow facility policy and call the back-up pharmacy to obtain the needed insulin. The nurses also failed to make the supervising nurse on duty, the DON, or the Executive Director aware the resident did not have any of his insulin. Both nurses were aware of the facility’s policy/protocol. She stated both nurses were terminated and reported to the Board of Nursing. The Executive Director also revealed the current DON was not employed at the facility at the time of the incident.