Failure to Assess and Intervene for High Blood Sugar Episodes
Penalty
Summary
The facility failed to assess and intervene appropriately for two residents with diabetes who experienced multiple episodes of high blood sugar (hyperglycemia). For one resident with a history of diabetes, hemiplegia, and seizure disorder, the care plan directed staff to observe for signs of hyperglycemia, and the medication order required staff to administer insulin and notify the provider for blood sugars over 399 mg/dl. However, the electronic health record showed several blood sugar readings above this threshold without documentation of provider notification or follow-up interventions. Similarly, another resident with diabetes, heart failure, and anxiety had care plan instructions for monitoring medication effectiveness and orders for insulin administration. Despite blood sugar readings above 400 mg/dl, there were no documented provider notifications or follow-up actions. Staff interviews revealed inconsistent understanding of when to notify providers about high blood sugar levels, and the Director of Nursing acknowledged poor documentation practices and agreed that staff should have contacted the provider for abnormal blood sugars.