Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
Staff at the facility failed to follow physician orders regarding blood glucose monitoring for one resident with diabetes mellitus and other comorbidities. The physician had ordered blood glucose checks four times daily, with instructions to notify the provider if levels exceeded 400 mg/dL or dropped below 60 mg/dL. Over a three-month period, the resident's blood glucose readings fell outside these parameters on eight occasions, but there was no documentation that the physician was notified as required. The resident's care plan also specified that abnormal blood glucose levels should be reported to the physician. Review of the electronic chart and interviews with staff confirmed that notifications were not made, even though the facility's policy required physician notification for significant changes in resident health status. One LPN admitted to being aware of high blood glucose readings but did not recall the notification parameters and had never contacted the physician. The regional clinical specialist confirmed that staff were expected to follow through with physician notification when ordered parameters were met.