Failure to Notify Physician of Repeated Low Blood Sugar Events
Penalty
Summary
The facility failed to immediately notify and consult with a resident's physician when there was a significant change in condition for one resident with type 2 diabetes mellitus who was receiving insulin therapy. The resident experienced multiple episodes of low blood sugar (below the ordered parameter of 70 mg/dL), as documented in the Medication Administration Record, with values as low as 48 mg/dL on several mornings. Despite physician orders requiring notification if blood glucose was less than 70, there was no evidence that the physician or nurse practitioner was notified for each incident. Progress notes also lacked documentation of physician notification for several of these low blood sugar events. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to notify the physician or nurse practitioner for blood sugars below 70, regardless of the resident's hospice status. However, the Director of Nursing acknowledged that the required notifications were not made for each low blood sugar occurrence. The facility's own policy and staff statements supported the need for immediate notification, but this was not consistently followed, resulting in a deficiency.