Failure to Notify Physician of Abnormal Blood Sugar Readings
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of abnormal blood sugar readings for a resident with diabetes mellitus type 2, diabetes with polyneuropathy, and acute kidney failure. The resident, who was cognitively intact and receiving insulin injections, had physician orders specifying that the physician should be notified for blood sugar readings below 70 mg/dL or above 400 mg/dL. Despite this, blood sugar readings of 60 mg/dL and 59 mg/dL were documented, and there was no evidence that the physician had been notified as required by the orders. Interviews with staff confirmed that the physician should have been notified of these low blood sugar readings, and facility policy required nursing staff to contact the physician based on the urgency of the situation. The lack of documentation and notification was acknowledged by both the LPN and the Assistant Director of Nursing, indicating a failure to follow established protocols for monitoring and responding to acute changes in the resident's condition.