Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of multiple elevated blood glucose levels as required by the resident's physician orders. The orders specified that the physician should be called if the resident's blood glucose level was between a certain range, but review of the electronic Medication Administration Record (eMAR) showed several instances where the resident's blood glucose levels were significantly elevated, ranging from 360 mg/dL to 433 mg/dL. Despite these elevated readings, there was no documented evidence that the physician was notified as directed by the orders. Interviews with the Director of Nursing confirmed that nursing staff were expected to notify the physician for any blood glucose level above 352 mg/dL, but the facility was unable to provide documentation that such notifications occurred for the elevated readings identified. This deficiency was identified for one resident out of five sampled for unnecessary medications, based on both record review and staff interviews.