Failure to Notify Physician of Out-of-Range Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar level exceeded the parameters set by the physician. The resident, who had a history of diabetes mellitus and a recent diagnosis of hyperglycemia following a hospital visit, had a blood sugar reading of 343, which was above the physician-ordered threshold of 250. There was no documentation in the nursing progress notes that the physician was notified of this elevated blood sugar level, nor that any new orders for insulin were obtained. The resident's care plan specifically required that blood glucose levels outside of set parameters be reported to the physician. Interviews with nursing staff and the Director of Nursing confirmed that it was the responsibility of licensed nurses to notify the physician and document any response or new orders when blood sugar levels were out of range. The Director of Nursing was unable to find any evidence that the physician had been notified regarding the abnormal blood sugar level. Additionally, the facility was unable to provide a policy specifically related to hyperglycemia management.