Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Facility staff failed to notify the physician when a resident's capillary blood glucose (CBG) levels exceeded the parameters set by the physician's order. The resident, who had diagnoses including diabetes and dementia, had a physician order requiring staff to check CBG three times daily and notify the physician if the CBG was less than 70 or greater than 350. Despite multiple documented instances where the resident's CBG was above 350, there was no evidence in the clinical record that the physician was notified. Interviews with staff revealed a misunderstanding of the notification threshold, with staff believing physician notification was only necessary if the CBG exceeded 450, contrary to the physician's order.