Failure to Notify Physicians of Abnormal Blood Sugar Levels
Penalty
Summary
The facility failed to notify physicians of abnormal Capillary Blood Glucose (CBG) levels for four residents, as required by their care plans and physician orders. The facility's policy on diabetes management mandates that staff incorporate physician-ordered parameters for blood sugar monitoring into the Medication Administration Record (MAR) and care plan. However, the review of clinical records revealed that staff did not notify physicians of elevated or decreased blood sugar levels for Residents R7, R18, R19, and R20, despite these levels exceeding the thresholds set by their respective physician orders. Resident R7, diagnosed with coronary artery disease and diabetes, had multiple instances of elevated blood sugar levels, some as high as 600 mg/dL, without documentation of physician notification. Similarly, Resident R18, with multiple sclerosis and diabetes, had several elevated blood sugar readings above the physician-ordered threshold of 341 mg/dL, yet there was no evidence of physician notification. Resident R19, diagnosed with COPD and diabetes, also had elevated blood sugar levels exceeding 400 mg/dL without documentation of physician notification. Resident R20, with paraplegia and diabetes, had a significantly low blood sugar level of 38 mg/dL, but there was no documentation of reassessment or treatment for this low blood sugar. The Nursing Home Administrator and the Director of Nursing confirmed during an interview that the facility failed to notify physicians of these abnormal CBG levels for the four residents, indicating a lapse in adherence to the facility's diabetes management protocol.
Plan Of Correction
Facility is unable to retroactively correct identified notification for R7 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. Facility is unable to retroactively correct identified notification for R18 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. Facility is unable to retroactively correct identified notification for R19 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. Facility is unable to retroactively correct identified notification for R20 blood sugar out of range for dates specified. Physician was made aware of trend in glucoses over this period. Medication was reviewed with physician to ensure order is appropriate. DON/designee will conduct a facility-wide audit of residents with sliding scale orders to ensure blood sugar values are reviewed, documentation of physician notification per ordered parameters, evidence of follow-up and resident response to abnormal readings. No negative findings. All licensed nursing staff will receive mandatory in-service training by DON on interpreting provider-specific glucose parameters, timely physician notification procedures, documentation expectations, and diabetes management protocol by 4/30/25. DON/designee will conduct audits 5 times per week for 4 weeks, then 3 times per week for 2 weeks on residents EMR with blood sugar out of range contains documentation of physician notification per ordered parameters, evidence of follow-up and resident response to abnormal readings.