Failure to Follow Diabetes Management Policy and Physician Orders for Monitoring
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with multiple diagnoses, including type 2 diabetes mellitus, chronic kidney disease, cervical vertebra fracture, and traumatic subdural hemorrhage. The facility did not follow its own diabetes management policy, which required blood glucose monitoring twice daily for residents on insulin. Instead, the resident's blood sugar was only checked once daily at bedtime, despite significant fluctuations and increases in blood glucose levels. Additionally, there was no documentation that the physician was notified when the resident's blood sugar rose sharply from 89 mg/dL to 380 mg/dL. The facility also failed to follow physician orders regarding monitoring and notification for low oxygen saturation (O2 sat). The resident's O2 sat was repeatedly below the ordered threshold of 94% on multiple shifts, but there was no evidence that the physician was notified as required. Ultimately, the resident experienced a critical decline, with an O2 sat of 78% and a blood glucose of 588 mg/dL, resulting in transfer to the hospital. Interviews with facility staff confirmed these failures to follow both facility policy and physician orders.