Failure to Notify Physician of Elevated Blood Sugar and Inadequate Monitoring for Insulin Administration
Penalty
Summary
A resident with multiple diagnoses, including diabetes type 2, was prescribed insulin glargine with specific physician orders to notify the physician or nurse practitioner if fingerstick blood sugar (FSBS) readings were below 100 or above 300 mg/dl. The resident's medical records showed several instances where FSBS readings exceeded 300 mg/dl at the time insulin was scheduled to be administered. Despite these elevated readings, there was no documentation that the physician or nurse practitioner was notified as required by the orders. Additionally, the resident's orders included monitoring for signs and symptoms of hypoglycemia, but there were no documented parameters or orders for monitoring hyperglycemia. The facility's policies required prompt reporting of abnormal blood sugar results and appropriate documentation, but these procedures were not followed in this case. The Director of Nursing confirmed the lack of documentation and monitoring for hyperglycemia, as well as the absence of required notifications to the physician or nurse practitioner.