Failure to Monitor and Report Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to properly assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for five residents. These residents, who had diagnoses including diabetes, were not monitored according to the facility's policies and physician orders. The facility's policy required documentation of CBG levels, interventions to stabilize blood glucose, and timely communication with physicians when there was a change in a resident's condition. However, the facility did not adhere to these protocols. For Resident R13, multiple instances of hyperglycemia were recorded, with CBG levels significantly above normal. Despite these readings, there was no evidence that the resident was assessed for hyperglycemia, nor was there documentation of any interventions or physician notifications. Similar failures were noted for Residents R26, R28, R29, and R46, where high or low CBG levels were recorded, but the necessary follow-up actions, including rechecking blood sugar levels and notifying physicians, were not documented. Interviews with nursing staff revealed inconsistencies in the actions taken when abnormal CBG levels were detected. Staff members described different procedures for addressing high and low blood glucose levels, indicating a lack of standardized practice. The Director of Nursing confirmed the facility's failure to notify physicians of changes in condition, document assessments or interventions, and follow physician orders for the affected 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 R13, R26, R28, R29 and R46. The previous residents R13, R26, R28, R29 and R46 physicians were notified/will be notified of abnormal CBG results for any new orders. 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.