Failure to Follow Hypoglycemia Protocol and Physician Orders Results in Immediate Jeopardy
Penalty
Summary
The facility failed to administer care in a manner that ensured effective and efficient use of resources to maintain the highest practical well-being of each resident, as evidenced by the handling of a resident experiencing hypoglycemia. The resident, who had a history of Type 2 Diabetes Mellitus and was under orders for regular blood glucose monitoring and emergency glucagon administration for low blood sugar, experienced a series of hypoglycemic episodes. On one occasion, the resident's blood sugar was found to be 72, and an LPN administered glucose gel without a physician's order and did not notify the provider. Subsequently, the resident became less responsive, and later, a critically low blood sugar of 42 was recorded. The on-call physician was contacted and ordered glucagon administration, monitoring, and transfer to the emergency room if there was no positive response. Despite these orders, when the resident's blood sugar dropped again 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 per the physician's instructions. Documentation was incomplete, and there was a lack of timely and appropriate follow-up on the resident's deteriorating condition. Interviews with staff and review of records revealed that the nurse did not document all blood sugar checks, did not follow the expected protocol for hypoglycemia management, and lacked documented competency training regarding glucagon administration. The DON and other clinical leaders were not promptly informed, and the incident was not identified as a reportable event or brought to the facility's QAPI process in a timely manner. The resident ultimately became unresponsive and was transported to the hospital, where they did not survive. The facility's failure to implement its policies and procedures for change in condition, notify the physician as required, and follow physician orders for hypoglycemia management resulted in a determination of Immediate Jeopardy. This deficiency placed all residents at risk who might experience a change in condition requiring prompt and appropriate intervention.
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 one on one 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.
- VPCS (Vice President of Clinical Services) reeducated the Clinical Management Team including the Administrator and Director of Nursing on the components of job descriptions.
- The Administrator/designees and Director of Nursing Services designee will ensure that the safety and well-being as it related to blood glucose monitoring and treatment is maintained by the continued participation, evaluation, and intervention through Dashboard, Risk reports, RTH Resident records and hour report review during clinical standup and stand down meeting, and maintaining QA/PI (Quality Assurance/Performance Improvement) process.