Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of significant changes in the resident's condition, specifically elevated blood glucose levels, as required by physician orders. The resident, who was cognitively impaired and had diagnoses including Type 2 Diabetes Mellitus and Atherosclerotic Heart Disease, had physician orders in place to notify the physician if blood sugar levels exceeded 350 mg/dl or dropped below 70 mg/dl. On two occasions, the resident's blood sugar levels were recorded as 376 mg/dl and 355 mg/dl, but there was no documentation that the physician was notified of these elevated readings. Review of the clinical record and interviews with the Director of Nursing confirmed that there was no evidence of physician notification for the elevated blood sugar levels on the specified dates. The DON acknowledged that documentation of physician contact should be present in the clinical record and confirmed that the physician should have been notified according to the standing orders. The lack of notification and documentation constituted a failure to follow physician orders and facility policy regarding significant changes in a resident's condition.