Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
A resident with a diagnosis of type 2 diabetes mellitus and severely impaired cognition was dependent on staff for all activities of daily living. The resident's care plan and physician orders required blood glucose monitoring four times daily, with instructions to notify the physician if blood sugar levels were less than 60 mg/dl or greater than 400 mg/dl. During the review period, the resident had two documented blood sugar readings above the ordered parameters: one at 435 mg/dl and another at 499 mg/dl. Despite these elevated blood sugar readings, there was no evidence in the resident's progress notes that the physician was notified as required by the care plan and physician orders. Interviews with nursing staff confirmed that the expectation was to notify the physician for blood sugars outside the specified range to obtain further orders. The facility did not provide a policy regarding unnecessary medications.