Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders regarding diabetes management for a resident, identified as Resident R24. The resident, who was admitted to the facility in March 2021, had a diagnosis of diabetes, which requires careful monitoring of blood glucose levels. According to the physician's order dated May 23, 2023, the facility was required to check the resident's blood glucose levels and notify the physician if the levels exceeded 400. However, the facility did not comply with this order. The clinical records revealed multiple instances where Resident R24's blood glucose levels exceeded 400, specifically on several dates between November 2025 and January 2025, with levels ranging from 407 to 427. Despite these elevated readings, there was no documentation indicating that the physician was notified as required. This deficiency was confirmed during an interview with Employee E13, the unit manager, who acknowledged the findings.
Plan Of Correction
1. Physician reviewed resident R24 blood glucose levels for last 7 days with no changes to orders. 2. The Director of Nursing or designee will conduct an initial audit of current residents with physician orders for blood glucose levels with parameters for the last 7 days to ensure out of range parameters are reported to the physician. 3. NPE or designee will educate current licensed nurses on diabetes management and ensure physician is notified when blood glucose parameters are out of range. 4. The DON or designee will conduct weekly random audits of 5 residents per week x 12 weeks of residents with accu-checks to ensure that blood sugars out of range were reported to the physician. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.