Failure to Assess and Notify Physicians of Abnormal Conditions
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal Capillary Blood Glucose (CBG) levels for a resident with diabetes mellitus. The resident, who had a history of chronic obstructive pulmonary disease, chronic kidney disease, and diabetes, had a CBG level of 500 noted in their electronic Medication Administration Record (eMAR). Despite this critical level, the facility did not assess the resident for hyperglycemia, monitor the effectiveness of treatment, follow the care plan interventions, or notify the physician of the abnormal result. Additionally, the facility did not appropriately respond to a change in condition for another resident who had fallen during a family visit, resulting in an open wound on the right knee. The clinical record lacked an assessment of the wound, and the physician was not notified. Furthermore, the facility failed to obtain a physician order for the wound care for 14 days, and there was no documentation of the wound's description or measurements for 13 days. These deficiencies were confirmed during interviews with the Vice President of Clinical Services, who acknowledged the facility's failure to adhere to policies regarding the assessment, documentation, and notification of changes in residents' conditions.
Plan Of Correction
R134 and R368 did not experience a negative outcome. Residents that require sliding scale insulin will have results reviewed from last week to present to determine if the resident was noted with a hyperglycemic episode and if the resident was assessed and physician was notified. Nursing notes will be reviewed for 1 week to present for any new skin conditions and proper documentation is in place with measurements and treatment orders. Education to be performed with licensed nursing staff on the importance of MD notification of hypo/hyperglycemia and assessment as well as new or change in skin condition with proper documentation and treatment order. Audits on short acting insulin with a sliding scale for above or below will be conducted 3x a week times 2 weeks, 2x a week x2 weeks, and 1x a week x2 weeks to ensure orders followed and physician notifications are met. Audit new skin conditions to ensure measurements and orders are documented timely by review of nursing notes and orders. 3x a week times 2 weeks, 2x a week times 2 weeks, and 1x a week times 2 weeks.