Failure to Notify Physician of Elevated Blood Sugar per Order
Penalty
Summary
A physician's order for a resident with diabetes, schizophrenia, dementia, and psychotic disturbance was not followed as required by professional standards. The resident had a physician's order for insulin Lispro to be administered according to a sliding scale, with instructions to notify the physician if the blood sugar value exceeded 401. On review of the electronic medication administration record, it was found that the resident's blood sugar was recorded at 411, and the nurse administered six units of Lispro insulin but did not notify the physician as directed in the order. During an interview and record review, a licensed nurse confirmed that the physician was not notified of the elevated blood sugar value, and acknowledged that the nurse did not follow the physician's order. No documentation was found in the nursing progress notes or medication administration record indicating that the physician was contacted. Additionally, when a policy and procedure on following physician orders was requested, the facility was unable to provide one.