Failure to Hold Glipizide for Low Blood Sugar Levels
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes mellitus and hypertension was administered Glucotrol (Glipizide) despite physician orders to hold the medication if blood sugar (BS) levels were less than 120 mg/dL. The resident's medical records indicated moderate cognitive impairment and a need for supervision with eating, as well as maximal assistance with other activities of daily living. The medication order specifically instructed staff to withhold Glipizide for BS readings below the prescribed threshold. Despite these orders, the resident received Glipizide on multiple occasions when their BS was below 120 mg/dL, with documented readings of 118, 119, 103, 115, and 97 mg/dL. During an interview and record review, an LVN confirmed that the medication was administered outside the prescribed parameters and acknowledged that this could further lower the resident's blood sugar. The facility's policy required staff to hold medications for vital signs outside physician-prescribed parameters, but this was not followed in these instances.