Failure to Notify Provider and Respond to Diabetic Change in Condition
Penalty
Summary
A resident with multiple complex medical conditions, including insulin-dependent type 2 diabetes mellitus, congestive heart failure, depression, anorexia, and acute osteomyelitis, experienced a significant change in condition when he refused all scheduled medications, including diabetic medications, on both the morning and evening of a specific day. Despite a fasting blood glucose reading of 388 mg/dL in the morning and a subsequent reading of 513 mg/dL in the evening—both well above the facility's standing order threshold for physician notification—there was no evidence that staff notified the resident's physician of either the medication refusals or the dangerously high blood glucose levels. The resident's care plan specifically directed staff to observe for symptoms of high blood sugar and to report changes in condition to the nursing staff or physician, but these directives were not followed. The resident's electronic medical record and medication administration records lacked documentation of any provider notification regarding the medication refusals or abnormal blood glucose levels. Additionally, there were no progress notes entered for the days in question, despite the resident's significant change in status. Interviews with nursing staff and administrative personnel confirmed that facility protocol required provider notification for blood glucose levels above 350 mg/dL and for medication refusals, but these protocols were not adhered to in this case. Staff also reported that charting was done by exception, and no notes were made because the resident was perceived as lucid and responding appropriately, despite the abnormal clinical findings. The failure to promptly identify and respond to the resident's change in condition, including the lack of immediate physician involvement, resulted in the resident becoming unresponsive the following morning and requiring emergency hospitalization. The facility's own investigation confirmed that the responsible nurse did not perform required duties related to medication administration and documentation. This series of inactions constituted a failure to provide necessary care and services as required by the resident's care plan and facility policy.