Failure to Assess, Document, and Notify Physicians of Abnormal Blood Glucose and Resident Condition Changes
Penalty
Summary
The facility failed to assess, document, and notify physicians of abnormal capillary blood glucose (CBG) levels for three residents with diabetes. For these residents, there were multiple instances where CBG readings were either extremely high (noted as 'HI' on the glucometer) or low, but staff did not follow physician orders or care plan interventions that required assessment, documentation, and physician notification for such results. Specifically, the clinical records and electronic medication administration records (eMAR) showed that staff did not assess for signs and symptoms of hyperglycemia or hypoglycemia, did not monitor the effectiveness of any interventions, and did not notify the physician as required by the residents' individualized orders and care plans. Additionally, the facility failed to appropriately respond to a change in condition for a resident with Alzheimer's disease and pulmonary hypertension. This resident exhibited a significant and sustained increase in heart rate, behavioral changes, and signs of possible infection, including blood in the brief and increased aggression. Despite these changes, there was a delay in assessment, documentation, and physician notification. The resident was eventually hospitalized for urinary tract infection, dehydration, hypernatremia, and atrial fibrillation with rapid ventricular response, but the initial signs and symptoms were not promptly addressed by the facility staff. Interviews with nursing staff and the Director of Nursing confirmed that the facility did not follow required protocols for assessment, documentation, and physician notification regarding abnormal blood glucose levels and changes in resident condition. The facility also lacked a specific policy for the care of diabetic residents, further contributing to the deficiencies identified during the survey.