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 care. Resident R1, who has diabetes, legal blindness, and high blood pressure, had orders for managing hypoglycemia and hyperglycemia, including specific protocols for administering insulin and emergency glucagon. However, on two occasions, the resident's CBG levels were recorded as significantly low, yet there was no documentation of assessment for hypoglycemia, monitoring of treatment effectiveness, or physician notification as required by the care plan. Similarly, Resident R12, diagnosed with diabetes, high blood pressure, and anxiety, had orders for managing blood glucose levels, including a sliding scale for insulin administration. Despite this, the resident experienced both extremely high and low CBG levels on multiple occasions. The facility failed to assess for hyperglycemia, recheck blood sugar levels, or notify the physician of these abnormal results, contrary to the care plan interventions. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed these failures. The Director of Nursing acknowledged the lack of physician notification, documentation of assessments, and adherence to physician orders for both residents. Additionally, it was revealed that the facility lacked specific policies regarding diabetic care, relying instead on general nursing standards.