Failure to Notify Physician and Implement Hypoglycemia Protocol for Diabetic Residents
Penalty
Summary
The facility failed to notify the physician of decreased capillary blood glucose (CBG) levels as required by physician orders and did not implement the hypoglycemia protocol for two residents with diabetes. For one resident with diagnoses including depression, coronary artery disease, and diabetes, blood glucose readings below 70 mg/dL were recorded on multiple occasions, including values as low as 53 mg/dL and 59 mg/dL. Despite physician orders to call the physician for CBG readings less than 70 mg/dL, there was no documentation that the physician was notified or that the hypoglycemia protocol was followed during these incidents. Another resident with diagnoses of high blood pressure, diabetes, and hyperlipidemia also experienced hypoglycemic episodes, with blood glucose readings of 49 mg/dL and 61 mg/dL. Although the resident was treated with orange juice and graham crackers and blood glucose was rechecked, the physician was not notified as required by the physician order and facility protocol. The Director of Nursing confirmed that the facility did not notify the physician or fully implement the hypoglycemia protocol for these residents.