Failure to Document Physician Notifications for Blood Sugar Levels
Penalty
Summary
The facility failed to appropriately document physician notifications for three residents, identified as R7, R8, and R9, regarding their blood sugar levels. The facility's policy requires that all services provided to residents, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, the review of the residents' records revealed that there were multiple instances where blood sugar levels exceeded the parameters set by physician orders, yet the notifications to physicians were not documented in a timely manner. For Resident R7, there were numerous instances of blood sugar levels exceeding 400 mg/dL, as per the hypoglycemia protocol, which required physician notification. Despite this, the progress notes indicated late entries for these out-of-range levels, created by the Director of Nursing (DON) on a single day, suggesting that the notifications were not made at the time of the incidents. Similarly, Resident R8 had blood sugar levels above 341 mg/dL, and Resident R9 had levels above 400 mg/dL, both requiring physician notification. Again, late entries were made by the DON, indicating that the notifications were not documented contemporaneously. The DON confirmed during an interview that the late entries were based on audits of the charts and that there was a book at the nurses' station for documenting physician notifications. However, the provided documentation showed entries in the same handwriting, raising concerns about the accuracy and authenticity of the records. The Nursing Home Administrator and the DON acknowledged the failure to appropriately document physician notifications for the three residents, which is a violation of the facility's policy and regulatory requirements.
Plan Of Correction
On 03/27/25, the Director of Nursing (DON) reviewed the medical records of Residents R7, R8, and R9. While some late entries existed, it was confirmed that not all physician notifications had been made or documented at the time of abnormal blood glucose results. The physician of record for each resident was contacted and updated on: - Past abnormal blood sugar values - Current status and any necessary follow-up The residents' plans of care were reviewed and updated to emphasize immediate reporting and documentation expectations for critical blood sugar readings. A facility-wide audit of diabetic residents with orders for sliding scale was conducted by DON, specifically reviewing: - Physician orders for blood sugar parameters - Blood glucose logs (CBG) - Progress notes and documentation of provider notification to ensure that orders are followed. By 4/30/25, mandatory in-service training will be conducted by DON/designee for all licensed staff on: - Diabetic Protocol - Proper documentation and notification practices. DON/designee will conduct audits 5 times per week for 4 weeks, then 3 times per week for 3 weeks on verified physician/family notification for out-of-range CBG results and treatments per order.