Failure to Manage Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal Capillary Blood Glucose (CBG) levels for two residents, leading to a deficiency in the quality of care. The facility's policies require timely communication with physicians and documentation of changes in a resident's condition, but these were not followed. Specifically, the facility did not adhere to its own protocols for managing diabetes-related complications, such as hypoglycemia and hyperglycemia, which are critical for residents with diabetes. Resident R51, who was admitted with diagnoses including hypoglycemia and diabetes, had several instances of abnormal CBG levels that were not properly managed. On multiple occasions, the resident's CBG levels were either too low or too high, yet there was no evidence of assessment for hyper-/hypoglycemia, monitoring of treatment effectiveness, or physician notification. The care plan interventions, which included monitoring for signs and symptoms of glucose level abnormalities and notifying the physician, were not followed. Similarly, Resident R66, who also had a diagnosis of diabetes, experienced numerous instances of elevated CBG levels. Despite the care plan's directives to perform Accuchecks and notify the physician of abnormal results, the facility failed to assess for hyperglycemia, recheck blood sugar levels, or notify the physician. This lack of adherence to the care plan and facility policies contributed to the deficiency in providing quality care to the residents.
Plan Of Correction
The facility will assess, document and notify the physician of increased and decreased Capillary Blood Glucose (CBG) levels for all residents. The facility cannot retroactively correct the concerns identified for residents R51 and R66; however, in the future, any increased or decreased CBG, the physician will be notified. All diabetic residents' orders will be reviewed to ensure accuracy/need for physician notification. The facility will complete a two-week look back of diabetic residents to validate the physician was notified of increased or decreased CBG, and the resident was assessed for hypoglycemia and documented. The Director of Nursing or designee will re-educate licensed nurses on the facility policy and procedures for Notifying the Physician with resident change in condition, detailing notification of increased or decreased CBG. The Director of Nursing or designee will complete an audit three times a week for four weeks, then monthly for three months to validate physicians are notified of any increased or decreased blood sugars and residents are assessed for hypoglycemia. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.