Failure to Perform Blood Glucose Check for Symptomatic Diabetic Resident
Penalty
Summary
A diabetic resident with a history of brittle diabetes, bilateral above-the-knee amputations, and other medical conditions reported symptoms consistent with hypoglycemia, including feeling lightheaded and sweaty. The resident requested that his blood sugar be checked by the assigned LPN, but the nurse stated she was busy and did not immediately perform the blood glucose check. The resident, feeling unwell and concerned, returned to his room and called 911 for assistance. Paramedics arrived and found the resident exhibiting signs of hypoglycemia, such as pallor and sweating. The paramedics checked the resident's blood sugar, which was found to be dangerously low at 42 mg/dL. The LPN told the paramedics that she had not checked the resident's blood sugar and claimed she did not have an order to do so, despite the resident having physician orders for blood sugar monitoring as needed and specific instructions for hypoglycemia management. The resident was given a Glucerna drink and transported to the hospital, where his condition improved. Facility staff interviews confirmed that glucometers were available and that the resident was cognitively intact and able to communicate his needs. The Director of Nursing and other staff acknowledged that the resident's request for a blood sugar check should have been prioritized, especially given his symptoms and medical history. Documentation showed a gap in blood glucose monitoring during the relevant time period, and the facility was unable to provide a specific policy for diabetic management when requested.