Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner of significantly elevated blood glucose levels for two residents with diabetes, as required by physician orders. For one resident with type 2 diabetes, blood glucose readings exceeded the ordered notification threshold of 400 mg/dl on multiple occasions, specifically with values of 443 mg/dl, 546 mg/dl, and 436 mg/dl, without documentation that the physician or Nurse Practitioner was notified. Interviews with nursing staff and the Director of Nursing confirmed that the protocol was to notify the provider and document the notification in the progress notes, which was not done in these instances. Another resident with multiple diagnoses, including type 2 diabetes and acute kidney failure, had several blood glucose readings ranging from 319 mg/dl to 397 mg/dl over two days. Despite facility policy and staff statements indicating that elevated blood glucose levels should prompt notification of the physician and documentation in the progress notes, there was no evidence in the resident's record that the physician was notified of these abnormal results. The facility's policy required following physician orders and parameters, but this was not adhered to in these cases.