Failure to Notify Physician of Critically High Blood Sugar Levels
Penalty
Summary
The facility failed to notify the medical doctor (MD) when a resident experienced multiple episodes of significantly elevated blood sugar levels, as required by physician orders and facility policy. The resident, who had diagnoses including chronic kidney disease, diabetes mellitus, depression, and dementia, was admitted with a care plan that identified a high risk for hypo/hyperglycemia and required monitoring and reporting of abnormal blood sugar findings to the physician. The physician's order specifically instructed staff to call the MD immediately for blood sugar levels greater than 400 mg/dL and to document any change of condition. Record reviews revealed that the resident had several blood sugar readings over 400 mg/dL during the month, with values of 422, 451, 401, and 437 mg/dL on separate occasions. Despite these critical readings, there was no documentation in the Medication Administration Record (MAR), nurse progress notes, or change of condition assessments indicating that the MD was notified or that a change of condition was documented for any of these episodes. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that staff did not notify the MD as required and did not complete the necessary change of condition documentation. The facility's policy mandates immediate notification of the physician and resident representative in the event of significant changes in a resident's condition, which was not followed in this case.