Failure to Notify Physician of Critically High Blood Sugar Readings
Penalty
Summary
The facility failed to ensure that high blood sugar readings above 401 mg/dL were reported to the physician in a timely manner as ordered for one resident with diabetes and hypertension. According to the physician's order, insulin was to be administered based on a sliding scale, and the physician was to be notified if blood sugar levels reached 401 mg/dL or higher. On two occasions, a resident's blood sugar levels were recorded at 447 mg/dL and 442 mg/dL, and 12 units of insulin were administered each time by two different LVNs. However, there was no documented evidence that the physician was notified of these elevated readings as required by the physician's order. Interviews with the LVNs involved revealed that both nurses acknowledged they failed to contact the physician after recording the high blood sugar levels, citing reasons such as forgetting or being busy. The Director of Nursing confirmed that the expectation was for licensed nurses to follow physician orders regarding diabetic management and to treat out-of-range blood sugar checks as a change of condition requiring physician notification. Review of the facility's diabetes clinical protocol further supported the requirement for staff to report issues affecting diabetes management according to physician-ordered parameters.