Failure to Conduct IDT Review for Persistent Hyperglycemia
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice by not conducting an Interdisciplinary Team (IDT) review for a resident who experienced continuous episodes of hyperglycemia. The resident, who had multiple complex diagnoses including type 2 diabetes mellitus, dementia, and a feeding tube, was admitted and later readmitted to the facility. Medical records indicated that the resident's cognitive status was severely impaired and that she was unable to make her own decisions. Blood glucose monitoring showed consistently high levels ranging from 306 mg/dL to 500 mg/dL over a ten-day period. Despite these findings and a subsequent transfer to an acute care hospital for uncontrolled hyperglycemia, there was no documentation of an IDT meeting to address the resident's condition. Interviews with facility staff, including a registered nurse and the Director of Nursing, confirmed that no IDT documentation existed for the resident's episodes of hyperglycemia. The facility's policy and procedure required that care plans be reviewed and revised by the IDT after each assessment or significant change in condition, including issues related to diagnosis or health condition. The lack of an IDT review and care plan revision in response to the resident's persistent hyperglycemia constituted a failure to follow established protocols and professional standards of care.