Failure to Notify Physician and Responsible Party of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician and the resident's responsible party regarding multiple instances of elevated blood glucose levels for one resident. The resident had a history of atrial fibrillation, hypertension, edema, diabetes, a right ankle wound, and unspecified dementia. Physician orders required staff to notify the physician if the resident's blood sugar exceeded 400 mg/dL. Despite this, record review showed several occasions where the resident's blood sugar was above this threshold, including readings of 421, 445, 520, 400, and 418 mg/dL. There was no documentation indicating that the physician or responsible party had been notified of these critical values. Interviews with nursing staff confirmed that the protocol was to notify the provider and family immediately if blood glucose values were outside the critical range, and to document the change and notifications. The facility's own guidelines also required notification of any critical lab value. However, the clinical record lacked evidence that these notifications occurred for the resident's elevated blood glucose levels, constituting a failure to follow established procedures for change of condition notification.