Failure to Notify Physicians and Assess Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of abnormal capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, affecting two residents. Resident R7, diagnosed with diabetes, depression, and high blood pressure, had multiple instances of abnormal CBG levels that were not reported to the physician as required by the facility's policy. The resident's care plan included monitoring and reporting signs of hypo/hyperglycemia, but staff did not follow these interventions, nor did they document or assess the effectiveness of treatments. Similarly, Resident R38, also diagnosed with diabetes, depression, and high blood pressure, experienced low CBG levels that were not properly addressed according to the physician's orders. The resident's care plan required monitoring and reporting of hypo/hyperglycemia symptoms, but staff failed to follow these protocols. The physician was not notified of the abnormal CBG levels, and there was no documentation of assessment or intervention. Interviews with Licensed Practical Nurses (LPNs) revealed inconsistencies in the management of abnormal blood glucose levels, with some LPNs stating they would provide juice or snacks for low blood glucose and call the doctor for high levels, but these actions were not consistently documented or followed. The Director of Nursing confirmed the facility's failure to notify physicians, document assessments, and follow physician orders for the residents involved.
Plan Of Correction
1. Audit completed 12/11/2024 by DON/Designee for abnormal blood sugars and MD notifications. 2. All RN and LPN educated by DON/Designee on MD notification and follow up related to abnormal blood glucose levels. 3. DON/Designee will audit residents' diabetic glucose levels daily x 1 week. 4. DON/Designee will audit 10 residents' blood glucose levels weekly x 4 weeks, then monthly x 3 months.