Failure to Obtain Physician Order and Notify Physician for Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to obtain a physician order prior to performing fingerstick blood sugar level (BSL) checks for a newly admitted resident with diabetes mellitus and generalized muscle weakness. The resident's care plan required that medications, treatments, and other services be administered in accordance with physician orders. Despite this, nursing staff performed multiple BSL checks at the resident's request without a physician order on several occasions. Interviews with nursing staff confirmed that they were aware a physician order was required but proceeded with the checks regardless. Additionally, the facility did not notify the physician when the resident's BSL results were repeatedly above 189 mg/dL, with some readings as high as 400 mg/dL. Although a nurse stated that the physician was notified about the elevated BSLs, there was no documentation to support this communication, as required by the facility's policy on charting and documentation. The policy also specified that physician orders must be written and maintained, and that all physician notifications should be documented, which was not done in this case.