Failure to Notify Physician of Abnormal Glucose Levels
Penalty
Summary
The facility failed to notify a physician of abnormal glucose readings for a resident, identified as Resident R108, as per the physician's order. The facility's policy on diabetes management required staff to incorporate physician-ordered parameters for monitoring and reporting blood sugar levels into the Medication Administration Record (MAR). Resident R108, who was admitted with diagnoses including diabetes, had specific physician orders for insulin administration based on a sliding scale, with instructions to notify the physician if glucose levels exceeded 340. However, the review of Resident R108's glucose log revealed multiple instances where glucose levels were significantly above 340, yet there was no documentation of physician notification in the progress notes. The Director of Nursing confirmed during an interview that the facility did not notify the physician of the abnormal glucose readings as required. The resident's care plan emphasized the importance of monitoring and reporting symptoms of hyperglycemia, yet the facility failed to adhere to these protocols. This deficiency was identified under the regulations 28 Pa. Code: 201.14(a) and 28 Pa. Code 211.12(d)(1)(2)(3)(5), which pertain to the responsibility of the licensee and nursing services, respectively.
Plan Of Correction
The resident has been discharged from the facility so provider notification was not accomplished. RNs, LPNs, and Unit Managers will be educated by the Director of Nursing, In-Service Director or designee on the necessity of timely provider notification of the resident's blood glucose level pursuant to the provider's order. The facility will audit five random residents' blood glucose levels weekly for three weeks and compare these levels with the provider's order to ensure compliance. Subsequently, the facility will audit five random residents' blood glucose levels for three weeks bi-weekly. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.