Failure to Notify Physician of Elevated Blood Glucose Levels per Order
Penalty
Summary
The facility failed to ensure that a resident with Type 2 diabetes mellitus received care in accordance with professional standards and physician orders regarding blood glucose monitoring and physician notification. The resident had active physician orders requiring blood glucose checks at bedtime and notification of the physician if levels were less than 70 or greater than 300 mg/dl. Additionally, there was an order for PRN blood sugar checks with special instructions to recheck if over 350 mg/dl. Review of the Medication Administration Record showed that on two occasions, the resident's blood glucose levels were recorded as 343 mg/dl and 340 mg/dl, both above the threshold requiring physician notification. There was no documentation in the resident's progress notes that the physician had been notified of these elevated blood glucose readings. Interviews with the nurses involved revealed that one nurse did not recall notifying the physician and would typically document such notifications in the progress notes, while the other nurse misunderstood the threshold for notification, believing it to be over 350 mg/dl instead of 300 mg/dl as per the order. The Director of Nursing confirmed that the expectation was for nurses to notify the physician for blood glucose levels over 300 mg/dl and to document this in the medical record, and stated that if it was not documented, it was not done.