Failure to Notify Physician of Critically Low Blood Sugar
Penalty
Summary
A deficiency was identified when a nurse failed to notify a resident's physician of a critically low blood sugar result, as required by both physician orders and facility policy. The resident, who had intact cognition and a history of diabetes, hypertension, and chronic pain syndrome, had a blood sugar reading of 52, which was below the threshold specified in the physician's orders for mandatory physician notification. Review of the medical record and progress notes revealed no documentation that the physician was informed of this low blood sugar event. Interviews with nursing staff and the Director of Nursing confirmed that the physician should have been notified immediately and that documentation of this notification was required. The facility's policy on Notification of Changes also mandates prompt communication with the physician and the resident's representative when significant changes occur. The incident report further confirmed that the responsible nurse did not notify the physician as required.