Failure to Monitor Blood Glucose in Diabetic Resident on Insulin
Penalty
Summary
The facility failed to implement a system to ensure blood glucose monitoring for a resident with diabetes who was receiving insulin and tube feeding. Upon admission, the resident had a diagnosis of diabetes mellitus and was prescribed Lantus insulin twice daily, but there was no physician order for blood sugar monitoring, despite the resident's care plan identifying a risk for unstable blood glucose levels. The resident's hospital discharge records also did not include blood sugar monitoring orders, and this omission was not addressed by the facility's licensed nursing staff. On the morning of the incident, a licensed vocational nurse observed the resident experiencing convulsions, body shaking, and unresponsiveness, with no pulse or breathing. Despite the resident's diabetic status and the acute change in condition, the nurse did not check the resident's blood glucose level, stating uncertainty about the need to do so. Cardiopulmonary resuscitation was initiated, and emergency services were called, but the resident was pronounced dead shortly after. The facility's policy required blood glucose checks for diabetic residents on insulin, especially during changes in condition or when unresponsive, but this protocol was not followed. Interviews with facility staff, including the DON and the medical director, confirmed that blood glucose monitoring is standard practice for diabetic residents on insulin, particularly when there is a change in condition. The facility's own policies and procedures outlined the necessity of obtaining physician orders for blood glucose monitoring upon admission and during episodes of unresponsiveness. However, these procedures were not adhered to, resulting in the failure to monitor and respond appropriately to the resident's diabetic condition.