Failure to Recognize and Act on Change in Condition for Diabetic Resident
Penalty
Summary
The facility failed to recognize and appropriately act on a change in condition for a resident with a known diagnosis of diabetes mellitus type II. Upon admission, the resident's family provided a list of home medications, which included insulin, to the admission nurse. However, the nursing staff did not verify or clarify the continuation of insulin therapy with the primary care provider, nor did they document any communication regarding the resident's medication regimen. As a result, the resident did not receive insulin during their stay, despite having a care plan that identified diabetes and the need for monitoring and management of blood glucose levels. Throughout the resident's stay, blood glucose checks were performed three times daily, revealing values ranging from 79 mg/dl to 389 mg/dl, which were outside the normal range for diabetic management. Despite these abnormal readings and the resident experiencing symptoms such as nausea and malaise, there was no documentation that the nursing staff notified the primary care provider or initiated a change of condition protocol. The facility's policies required notification of the physician for significant changes in condition and for abnormal blood glucose readings, but these procedures were not followed. The resident's condition deteriorated over several days, culminating in severe symptoms including hypotension, nausea, vomiting, and malaise. The resident was ultimately transferred emergently to an acute care hospital, where they were diagnosed with uncontrolled hyperglycemia, diabetic ketoacidosis (DKA), and sepsis, requiring a nine-day hospitalization. Interviews with facility staff, including the DON, LVN, RN, and ADON, confirmed that medication reconciliation was not completed, insulin orders were not clarified or administered, and abnormal blood glucose results were not communicated to the physician, all of which contributed to the resident's acute medical crisis.