Failure to Notify Physician of Elevated Blood Sugar
Penalty
Summary
A deficiency occurred when staff failed to notify the physician of an elevated blood sugar level for a resident diagnosed with diabetes, schizophrenia, and chronic kidney disease. The resident's Medication Administration Record documented a blood sugar reading of 331, which is significantly above the normal range of 70-100. Physician orders in effect required staff to notify the physician of elevated blood sugar results, but did not specify exact parameters for notification. Review of the clinical record, nursing notes, and physician notes showed no evidence that the physician was informed of the elevated blood sugar. The resident's care plan included monitoring and documentation of side effects and effectiveness of treatment, as well as obtaining fasting serum blood sugar as ordered by the physician. During staff interviews, an LPN could not recall if he took the blood sugar reading but acknowledged that if he had, he should have notified the physician according to the order and facility policy. The LPN also stated that any provider notification would have been documented in the clinical record, but no such documentation was found. An APRN interviewed was unable to recall being notified of the elevated blood sugar and confirmed that no increased monitoring was directed following the abnormal result. The facility's Notification of Change policy required physician notification when a change occurred that required it, but this was not followed in this instance.