Failure to Notify Physician of Critically Low Blood Sugar Event
Penalty
Summary
The facility failed to notify a resident's physician when the resident experienced a critically low blood sugar level of 45 mg/dl. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, atrial fibrillation, and an above-knee amputation, was admitted with intact cognition and required varying levels of assistance with daily activities. On the date of the incident, a Licensed Vocational Nurse (LVN) administered orange juice as an intervention for the low blood sugar and rechecked the resident's blood sugar 15 minutes later, which had increased to 74 mg/dl. However, the LVN did not document physician notification, and during interviews, it was confirmed that physician notification and documentation were not completed as required. Facility policy required prompt notification of the physician and resident representative for changes in a resident's condition, including hypoglycemic events. The Assistant Director of Nursing (ADON) confirmed that the physician should have been notified and a Change of Condition form completed, regardless of the resident's blood sugar returning to normal after intervention. The facility's policy on diabetes care also specified immediate provider notification for hypoglycemia, which was not followed in this instance.