Improper Administration of Glucose Gel to Unresponsive Resident During Hypoglycemic Emergency
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of diabetes mellitus was found unresponsive with a critically low blood glucose level. The lead nurse administered glucose gel into the resident's mouth while the resident was unconscious and unable to follow commands. This action was observed by a paramedic who responded to the emergency and noted the presence of glucose gel in and around the resident's mouth. The nurse confirmed during interview that the resident was unresponsive at the time of administration. Facility policy for management of hypoglycemia, as well as staff interviews, indicated that in cases of unresponsiveness due to hypoglycemia, the appropriate intervention is to administer a glucagon injection, not oral glucose gel, due to the risk of aspiration or choking. The Director of Nursing and another licensed nurse both confirmed that the facility's policy requires glucagon administration in such situations, and that glucose gel should not be given to an unconscious resident.