Failure to Follow Hypoglycemia Protocol and Physician Orders Results in Immediate Jeopardy
Penalty
Summary
A facility failed to provide treatment and care according to professional standards of practice for a resident experiencing a change in condition related to hypoglycemia. The resident, who had a history of Type 2 Diabetes Mellitus and was under orders for regular blood glucose monitoring, experienced a series of low blood sugar readings. At one point, an LPN administered glucose gel without a physician's order and did not notify the provider of the resident's low blood sugar value. Subsequent blood sugar checks revealed further declines, and the resident became less responsive. Despite a physician's order to administer Glucagon intramuscularly if blood sugar dropped below 60 and to send the resident to the emergency room if there was no positive response, the facility did not follow these orders. When the resident's blood sugar dropped to 50 and then to 32, Glucagon was not administered as directed, the provider was not notified, and the resident was not sent to the emergency room as required. Documentation of blood sugar checks and interventions was incomplete, and the facility's policies for change in condition and physician notification were not followed. The resident was eventually transported to the hospital by emergency medical services but did not survive. Interviews with staff and review of records confirmed that physician orders were not followed, documentation was lacking, and professional standards for the management of hypoglycemia were not met. The failure to implement appropriate interventions and notify the physician placed all residents at risk and resulted in a determination of Immediate Jeopardy.
Removal Plan
- The DON/designee completed a comprehensive audit of active residents in the facility with orders for blood sugar monitoring to ensure insulin administration was documented to identify concerns related to insulin administration in accordance with physician orders including administration of hypoglycemia interventions with documentation of repeat blood sugars.
- The DON/designee completed a review of residents who return to the hospital to ensure timeliness of RTH (return to hospital) as it related to hypoglycemia was carried out.
- The DON/designee completed a comprehensive audit of active residents in the facility with change in condition to validate physician was notified and if blood sugar was completed as ordered.
- An Ad Hoc QA (Quality Assurance) meeting was held for investigation of the concern and determination of the root cause analysis.
- Staff A, LPN, received 1:1 education on hypoglycemia/hyperglycemia protocol, and change in condition.
- The facility initiated a systemic change to include the notification to the DON/ADON when hypoglycemic interventions are initiated.
- Licensed nurses received education on blood sugar monitoring, documentation of results, follow up with physician, guideline for diabetes management, policy and procedure on change in condition, and notification of DON/ADON (Assistant Director of Nursing) when hypoglycemic interventions initiated.