Failure to Provide Follow-Up for Critically Low Blood Sugar
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate follow-up assessment and intervention for a diabetic resident who experienced a critically low blood sugar (BS) result of 30 mg/dL. The resident, who had intact cognition and multiple diagnoses including diabetes mellitus, peripheral vascular disease, and paraplegia, reported a recent episode of low blood sugar. Clinical records showed that on the day of the incident, the resident's BS was recorded as 30 mg/dL by the facility's glucometer and 57 mg/dL by the resident's own meter. Despite this, there was no documentation of any intervention, such as providing carbohydrates or quick-acting sugar, nor was there evidence of a follow-up BS check or further progress notes for that day. Interviews with staff confirmed that the facility lacked a specific protocol for identifying and managing low blood sugar events, and that interventions and follow-up checks should have been documented. The resident did not receive a snack until several hours after the low BS reading, and there was no evidence that staff followed the care plan or the American Diabetes Association's guidelines for hypoglycemia. The Director of Nursing acknowledged that staff should have intervened and rechecked the BS within 30 minutes, but this was not done.