Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
Staff failed to follow physician orders and facility policy regarding the notification of blood glucose levels for a resident with type 2 diabetes mellitus. The resident's care plan and physician orders required staff to notify the physician if blood sugar readings were greater than 400 mg/dL or less than 60 mg/dL. Despite this, the electronic medical record showed that on two separate occasions, the resident's blood glucose levels exceeded 400 mg/dL (418 mg/dL and 409 mg/dL), and there was no documentation that the physician was notified as required. Interviews with licensed nurses and the administrative nurse confirmed that the standard practice and expectation was to contact the physician for blood sugars above 400 mg/dL, in accordance with the orders. The facility's policy also emphasized timely and effective communication of significant changes in resident status to the medical staff. However, the lack of documentation and notification in these instances demonstrated a failure to meet professional standards of care for the resident.