Failure to Provide Appropriate Hypoglycemia Management
Penalty
Summary
A deficiency occurred when a resident with diabetes and dementia, who required significant assistance with activities of daily living, did not receive appropriate care for a hypoglycemic episode. The resident was administered eight units of insulin after a high blood glucose reading, but subsequently consumed none of their dinner. Staff failed to ensure the resident ate after receiving insulin, which is necessary to prevent hypoglycemia, and did not monitor the resident's blood glucose levels following the meal refusal. Later that evening, the resident was found unresponsive. Staff checked vital signs but did not immediately check the resident's blood glucose level to rule out hypoglycemia. The blood glucose was not measured until paramedics arrived, at which point it was found to be critically low (40 mg/dl). There was no evidence that staff provided timely treatment for hypoglycemia, such as administering Glucagon or other interventions, nor did they consult the primary physician promptly for emergency orders. Record review revealed that the resident did not have a care plan addressing hypoglycemia, and there were no standing orders for Glucagon or other hypoglycemia treatments. Facility policies required glucose monitoring and treatment protocols for residents at risk, but these were not followed. The failure to monitor, treat, and provide appropriate interventions for hypoglycemia resulted in the resident's preventable hospitalization for further evaluation and treatment.
Plan Of Correction
F658 - Services Provided Meet Professional Standard • How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 23 was transferred to acute and returned to the facility on 11/2/24. Resident 23 has no hypoglycemic episode after returning from acute. The care plan was developed and implemented. (Exhibit #11) • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) reviewed the list of residents receiving insulin injection to ensure blood sugar monitoring was done and meal was offered after the insulin injection to prevent hypoglycemia episode. (Exhibit #12) No other resident affected of the same deficient practice. • What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Hypoglycemia Management," revised 12/19/2022. (Exhibit #13) Starting on 6/17/25, the QAN and DSD will conduct a weekly observation for three months to ensure licensed nurses are offering food and snacks after the insulin injection. (Exhibit #14) Starting on 6/17/25, the DON will conduct weekly review for three months to ensure residents receiving insulin will not have any hypoglycemic episode. If identified with hypoglycemic episode, a change of condition will be created, care plan will be revised and responsible party and physician will be notified for possible adjustment of the insulin. (Exhibit #15) The DON will also report to the administrator for any non-compliance. • How the facility plans to monitor its performance to make sure that solutions are sustained: The DON will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. The plan includes the following actions: - Starting on 6/17/25, the DON will conduct weekly review for three months to ensure residents receiving insulin will not have any hypoglycemic episode. If identified with hypoglycemic episode, a change of condition will be created, care plan will be revised and responsible party and physician will be notified for possible adjustment of the insulin. (Exhibit #15) - Starting on 6/17/25, the DON will report to the administrator for any non-compliance. The completion date for these actions is June 20, 2025.