Failure to Provide Person-Centered Diabetes Management and Physician Notification
Penalty
Summary
The facility failed to provide person-centered care and adhere to professional standards of practice in the management of diabetes for one resident. The resident, who was cognitively intact and had diagnoses including diabetes and end-stage renal disease on dialysis, did not have routine blood glucose monitoring ordered or documented for an extended period despite being prescribed diabetes medications. A consultant pharmacist recommended routine blood glucose monitoring, which was subsequently ordered for a two-week period. During this monitoring, several blood glucose readings exceeded the physician's notification threshold, but nursing staff failed to notify the physician as required, except for one instance. There was also no documentation of ongoing consultation with the physician regarding the resident's diabetes management needs. Additionally, the resident's care plan identified a risk for unstable blood sugars and directed staff to evaluate, record, and report effectiveness of interventions, but there was no evidence of a person-centered care plan addressing adequate diabetes management. The resident expressed a desire for more frequent blood glucose monitoring and was unable to recall the last time this was performed. The last documented blood glucose check was several months prior to the survey, and subsequent laboratory results showed elevated hemoglobin A1C levels. The Director of Nursing confirmed the lack of physician notification for elevated blood sugars and the absence of a person-centered care plan for diabetes management.