Failure to Respond to Changes in Condition and Elevated Blood Glucose
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents. One resident with multiple comorbidities, including chronic kidney disease and congestive heart failure, experienced several episodes of vomiting and diarrhea, as well as low blood pressure and altered mental status. Despite these changes in condition, staff did not implement adequate interventions to prevent dehydration, such as monitoring intake or providing supportive hydration. The resident's family repeatedly expressed concerns and ultimately insisted on hospital transfer, where the resident was diagnosed with colitis and severe dehydration due to norovirus. Documentation and interviews revealed that staff were aware of the resident's symptoms but did not escalate care or notify the physician in a timely manner, and there was a lack of comprehensive assessment and intervention for the resident's deteriorating condition. Another resident with Alzheimer's disease and type 2 diabetes had a significant increase in blood glucose levels, with readings rising from a baseline range of 143-246 mg/dL to 399 mg/dL and then 521 mg/dL over several days. Staff failed to notify the physician when the resident's blood sugar first exceeded their baseline and reached critical levels in the 300s, only acting after the blood sugar reached 521 mg/dL, at which point the resident was transferred to the hospital and diagnosed with uncontrolled diabetes and metabolic encephalopathy. The resident's care plan and facility policy required monitoring and physician notification for significant changes in blood glucose, but these protocols were not followed. Interviews with staff confirmed that there was no clear parameter for physician notification and that earlier intervention could have potentially prevented the hospital transfer. Both cases demonstrate a lack of timely assessment, monitoring, and communication with the physician regarding significant changes in residents' conditions. The facility's failure to follow established care plans and policies for monitoring, documenting, and responding to changes in condition resulted in adverse outcomes for both residents, including hospitalizations for severe dehydration and uncontrolled diabetes.