Failure to Address Endocrinology Consultation for Resident
Penalty
Summary
The facility failed to ensure that a recommendation for a resident to be seen by an endocrinologist was addressed. The resident, who had a history of diabetes, was seen by the facility endocrinologist, who recommended a follow-up in 2-4 weeks and advised the facility to contact them sooner if there were any concerns or changes in the resident's health status related to diabetes. Despite this, there was no evidence in the clinical record that the nursing staff scheduled an appointment or contacted the endocrinologist, even after a psychiatric nurse practitioner noted that the resident's behaviors might be linked to low blood sugar levels and advised consulting endocrinology. The resident exhibited various behaviors, including aggression towards staff and other residents, refusal of meals, and medication non-compliance, which were documented in multidisciplinary notes. The psychiatric nurse practitioner highlighted that the resident's condition worsened when blood sugar levels were low and recommended frequent blood sugar checks and a urinalysis to rule out other medical causes. However, these recommendations were not acted upon, and the Director of Nursing confirmed that the endocrinologist was not contacted regarding the resident's diabetes management concerns.
Plan Of Correction
The Facility does and shall ensure that endocrinologist services were provided for all residents to meet their spatialized health needs. All nursing staff have/will be educated regarding timely dental services for all residents. Monitoring and random checks will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and ongoing monitoring will be reported to the CQI Committee for a period deemed appropriate by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON