Failure to Provide Timely Diabetes Care and Monitoring
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus with diabetic peripheral angiopathy, sepsis due to methicillin susceptible staphylococcus aureus, and hyperglycemia did not receive timely treatment and care as ordered. The resident had physician orders for multiple diabetes medications, including Lispro insulin on a sliding scale, Metformin, and Tresiba. The orders specified that staff should notify the physician if the resident's blood sugar was less than 70 or greater than 400 mg/dL, and to recheck blood sugar 30 minutes after administering insulin if levels exceeded 400 mg/dL. Over several days, the resident's blood sugar readings were repeatedly above 400 mg/dL, with values as high as 502 mg/dL. Despite these elevated readings, documentation showed that blood sugar was not rechecked within the required 30-minute window after insulin administration, and there was a lack of timely notification to the physician or nurse practitioner as ordered. Nursing notes indicated that the nurse attempted to contact the physician and left a message, and was instructed by the DON to administer insulin and notify the nurse practitioner. However, the clinical record lacked documentation that the nurse practitioner was notified at the time of the high blood sugar readings, and blood sugar rechecks were delayed, sometimes not occurring until many hours later. Interviews with facility leadership confirmed these documentation gaps and delays in following the physician's orders for monitoring and notification. The facility's policy required timely and accurate documentation of resident information, which was not met in this instance.