Failure to Notify Provider of Change in Condition for Resident with Hyperglycemia and Tachycardia
Penalty
Summary
The facility failed to promptly notify a medical provider of a significant change in condition for a resident with multiple complex medical diagnoses, including diabetes, stroke, aphasia, and seizure disorders. The resident, who was nonverbal and received the majority of her nutrition via tube feeding, exhibited persistently elevated blood glucose levels over several days, with readings as high as 437, 413, and 397. Additionally, the resident's heart rate was consistently elevated, reaching up to 126 beats per minute, and her blood pressure was trending below baseline. Despite these abnormal findings, there was no documentation that a medical provider was notified of the resident's high blood sugars or tachycardia prior to her acute deterioration. Nursing documentation was notably lacking, with no progress notes entered for a period of nearly two weeks, and the only note during that time referencing a physician note with no new orders. Staff interviews revealed that while some staff recognized the abnormal blood sugar levels and vital signs, there was inconsistency in when to notify a provider, and no action was taken until the resident's condition became critical. When the resident's blood glucose became unreadable by the glucometer, a provider was contacted but did not give orders for insulin, only for tube feeding to be stopped and labs to be drawn. The resident was ultimately sent to the emergency department after further decline, where she was diagnosed with diabetic ketoacidosis, sepsis, and pneumonia. The lack of timely provider notification and absence of additional insulin administration outside of scheduled doses contributed to a delay in appropriate medical intervention. The facility's documentation and communication practices did not reflect prompt recognition or escalation of the resident's deteriorating condition, despite clear evidence of significant changes in vital signs and blood glucose levels.