Failure to Notify Physician and Monitor Blood Sugar per Orders in Diabetic Residents
Penalty
Summary
The facility failed to follow physician orders and established protocols in the management of diabetes for two residents. For one resident with a diagnosis of Type 1 diabetes mellitus and moderate cognitive impairment, the facility did not notify the resident’s physician when blood sugar (BS) levels fell below 85, as required by the physician’s orders. Multiple instances were documented where the resident’s BS was below 85, but there was no evidence in the progress notes or other records that the physician was informed of these low readings. Additionally, the facility did not adequately monitor the resident’s BS after administering Humalog Kwikpen insulin following breakfast and dinner, as ordered. The medication administration records showed that insulin was given as scheduled, but there was no documentation that BS was checked at the appropriate times or that the physician was notified when BS was below the specified threshold. The Director of Nursing confirmed that the orders for sliding scale insulin did not include additional BS checks at the times when Humalog Kwikpen was administered, and that this discrepancy was not clarified with the physician. Furthermore, the care plan for diabetes management did not include comprehensive interventions or protocols for hypoglycemia management specific to the resident’s orders. The care plan only stated a general goal to avoid signs and symptoms of hypoglycemia, without detailing actions to be taken for low BS readings or after insulin administration. Facility policies required prompt notification of changes in a resident’s condition and outlined procedures for hypoglycemia management, but these were not followed in practice for the residents involved.