Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to ensure physician notification occurred when a resident experienced significantly elevated blood glucose levels. The resident, who had multiple diagnoses including type 1 diabetes, end stage renal disease, malnutrition, and cognitive impairment, had blood glucose readings of 578 and 537 on consecutive checks. Despite these readings exceeding the highest range of the prescribed sliding scale for insulin administration, there was no documentation that a physician or on-call provider was notified to provide follow-up orders. Review of the resident's care plan and medication orders confirmed that insulin was to be administered according to a sliding scale, with specific instructions for blood glucose levels up to 450. Facility policy, as described by an LPN, required staff to notify the on-call provider for blood glucose readings over 450. However, progress notes only indicated that the end of the scale was given and a supervisor was notified, with no evidence of physician notification for the elevated readings. This deficiency was identified during a complaint investigation.