Failure to Notify Physician of Critically High Blood Sugar Levels
Penalty
Summary
Facility staff failed to follow physician orders for a resident with diabetes mellitus, sepsis, and kidney failure, who was at risk for complications of hypoglycemia and hyperglycemia. The resident's care plan and physician orders required staff to notify the physician if the resident's blood sugar exceeded 300 mg/dL. Blood sugar records showed multiple instances where the resident's blood sugar was above this threshold, but there was no documented evidence that the physician was notified as required. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed that the physician was not informed of the elevated blood sugar readings, and the facility's policy required such notification. The resident had severely impaired cognition and was dependent on staff to follow medical orders. The failure to notify the physician occurred on several occasions, despite clear orders and facility policy outlining the need for communication regarding abnormal blood sugar results.