Failure to Notify Physician of Out-of-Parameter Blood Glucose Readings
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels were outside of the parameters specified in the physician's orders. The resident in question had diagnoses of diabetes mellitus, major depressive disorder, and dementia, and required substantial assistance with daily activities. The care plan and physician's order directed staff to monitor blood glucose before meals and at bedtime, and to notify the physician if the blood glucose was greater than 300 mg/dL or less than 70 mg/dL. Despite this, the Medication Administration Record documented multiple instances where the resident's blood sugar readings were either above 300 mg/dL or below 70 mg/dL, and there was no evidence that the physician was notified as required. Staff interviews confirmed that the process for notifying the physician involved documenting the notification in a progress note, but review of the records did not show that such notifications occurred for the out-of-parameter blood glucose readings. The facility's policy required immediate consultation with the physician for significant changes in a resident's status, but this was not followed in the documented cases. The failure to notify the physician of abnormal blood glucose levels constituted a deficiency in ensuring the resident's drug regimen was free from unnecessary drugs and that care was provided according to physician orders.