Failure to Assess, Document, and Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to assess, document, and notify physicians of significant changes in capillary blood glucose (CBG) levels for three residents with diabetes. Despite having policies in place that required documentation of assessment data, notification of physicians for significant changes, and person-centered care planning, the facility did not follow these protocols. Specifically, multiple instances were identified where residents had elevated CBG readings well above the thresholds specified in physician orders, yet there was no evidence of assessment for hyperglycemia, monitoring for effectiveness of treatment, or physician notification. For one resident with dementia, diabetes, and aphasia, repeated CBG readings above 350 mg/dL were recorded, some exceeding 400 mg/dL. The physician's order required notification for CBG levels above 331 mg/dL, but there was no documentation of physician notification, assessment, or follow-up in the clinical record or eMAR. Similar failures were observed for two other residents with diabetes and other comorbidities, where CBG levels exceeded the notification threshold set by their physicians, but no corresponding documentation or notification was found. Additionally, care plans for these residents lacked person-centered interventions specific to their diabetic care needs. Interviews with nursing staff revealed inconsistent understanding and application of the facility's protocols regarding when to notify physicians and how to document interventions for abnormal blood glucose levels. Staff responses varied on the thresholds for physician notification and the steps to take in response to abnormal CBG readings. The Director of Nursing confirmed that the facility did not notify physicians of changes in condition, failed to document assessments or interventions related to blood glucose, and did not follow physician orders for the affected residents.
Plan Of Correction
Residents R58, R64, and R111. Doctors were notified of blood sugars out of parameters. A one-week review of 24-hour reports was conducted to assess the need for physician notification. The DON or designee will educate nurses on the need to notify the MD for all blood sugars out of range per order. The DON or designee will audit five diabetic residents for blood sugar MD notification weekly for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.