Failure to Timely Notify Provider of Change in Condition and Elevated Blood Sugars
Penalty
Summary
The facility failed to ensure timely notification of a physician regarding a resident's elevated blood sugars and significant change in condition. The resident, who had a history of diabetes mellitus and other complex medical issues, was admitted with orders to monitor blood sugars before meals and at bedtime, and to notify the provider if blood sugar was below 75 or above 400. On the day in question, the resident's blood sugar readings were 324 mg/dl in the morning, 400 mg/dl before lunch, and 451 mg/dl before supper. Despite these elevated readings, the provider was not notified promptly as required by the physician's orders and facility policy. Throughout the day, staff observed that the resident was more lethargic than usual, unable to feed himself, and exhibited a decline from his baseline functioning. Multiple staff members, including a trained medication assistant and a nursing assistant, noted these changes and reported them to the registered nurse on duty. However, the nurse did not immediately notify the provider after the first critical blood sugar reading, and a recheck of the blood sugar was not performed within the recommended timeframe. The nurse eventually contacted the provider later in the afternoon, but by that time, the resident's condition had further deteriorated, including hypoxia and altered mental status. Interviews with facility staff, the medical doctor, and the nurse practitioner confirmed that the provider should have been notified earlier about both the elevated blood sugars and the resident's change in condition. The facility's own policy required prompt notification of significant changes, but this was not followed. The delay in notification and assessment contributed to the resident being transferred to the hospital with acute medical issues, including sepsis, respiratory failure, and possible stroke. Documentation and communication lapses were also identified, such as missing provider orders and incomplete assessments.