Failure to Notify Physician of Missed Medication and Critical Blood Sugar Levels
Penalty
Summary
Facility staff failed to notify the physician when a resident's prescribed blood pressure medication, diltiazem, was not available for administration on multiple consecutive days. Documentation in the Medication Administration Record (MAR) indicated that the medication was not given on several occasions, but there was no evidence in the progress notes that the physician was informed about the unavailability of the medication as required. Additionally, staff did not notify the physician when the same resident experienced multiple episodes of significantly elevated blood sugar levels, with readings consistently above 400 mg/dL. The resident's physician orders specifically required staff to call the physician when blood sugar exceeded 400, but there was no documentation of such notifications in the progress notes. During interviews, the DON and regional nurse confirmed that staff did not contact the provider regarding either the missed medication or the high blood sugar levels.