Failure to Notify Physician of Erratic Blood Sugar Levels Resulting in Hypoglycemic Event
Penalty
Summary
The facility failed to notify the physician of a resident's fluctuating blood sugar (BS) levels, which were not reported despite being erratic and outside the normal range. The resident, who had diagnoses including type 2 diabetes mellitus, chronic kidney disease, and dysphagia, was admitted with specific dietary and insulin orders. The resident's blood sugar levels ranged from 83 to 328 mg/dL, but these variations were not communicated to the medical doctor as required by facility policy. On the day of the incident, the resident was found unresponsive with a blood sugar reading of 43 mg/dL, indicating hypoglycemia with altered mental status. Emergency interventions were initiated, including administration of glucagon and transfer to a general acute care hospital. Interviews with staff revealed that the licensed nurse did not notify the physician about the erratic blood sugar levels, believing the levels were at baseline, and failed to consider trends across all shifts. The director of nursing acknowledged that the physician should have been informed to adjust insulin dosages and prevent such episodes. Further review showed that the registered dietician had not reviewed the resident's blood sugar levels or meal intake, despite the resident's reduced food consumption, which could contribute to hypoglycemia. The facility's policy required notification of the physician and resident representative when significant changes in condition occurred, but this procedure was not followed, resulting in the resident experiencing a hypoglycemic event requiring hospitalization.