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 quality of care. Resident R20, who was re-admitted with diagnoses including diabetes, dementia, and high blood pressure, had instances where glucagon was administered, and CBG levels were recorded as low as 50 and 52. Despite these critical readings, the facility did not assess for hypoglycemia, monitor the effectiveness of treatment, or notify the physician as required by the care plan. Similarly, Resident R24, admitted with diabetes, high blood pressure, and depression, had a CBG level recorded at 438. The facility failed to assess for hyperglycemia, did not recheck the blood sugar, and did not notify the physician of this abnormal result, contrary to the care plan's interventions. The facility's policies on diabetic care and physician notification were not followed, contributing to the deficiency. Interviews with LPNs revealed inconsistencies in the actions taken when abnormal CBG levels were detected, with some staff indicating they would notify the doctor and recheck blood glucose, while others did not follow through with these steps. The Director of Nursing confirmed the facility's failure to notify the doctor, document assessments, and follow physician orders for the residents involved.
Plan Of Correction
I. R 20 and R24 were assessed with no negative outcomes found. II. A facility sweep of all residents on CBG's will be reviewed to ensure proper hypoglycemic protocol is in place. III. Director of Nursing/Designee will re-educate all licensed nursing staff on notification of change and hypoglycemic protocol policies and procedures. IV. Director of Nursing/Designee will conduct random audits of 10 residents weekly for 8 weeks to ensure proper hypoglycemic protocols and notifications are in place and documented. Audit results will be taken through Quality Assurance Committee meeting for tracking and trending purposes.