Failure to Respond to Acute Change in Condition for Diabetic Resident
Penalty
Summary
A deficiency occurred when staff failed to timely identify and respond to an acute change in condition for a resident with type 1 diabetes, chronic kidney disease, and other significant comorbidities. The resident, known to be a brittle diabetic, activated her call light during the night and reported to a CNA that her blood glucose was low and requested a snack. The CNA provided a snack but did not notify the nurse on duty of the resident's report of low blood glucose, nor did she return to check on the resident after the initial interaction. No further nursing assessment or monitoring was performed for the resident throughout the night. The nurse on duty, an LPN, had last seen the resident earlier in the evening when administering scheduled medications and insulin, relying solely on the resident's verbal report of her blood glucose reading from a continuous glucose monitoring device, without verifying the reading herself. The LPN did not make any rounds or assessments of the resident for the remainder of the night shift. The resident was not checked on again until her husband arrived in the morning and found her unresponsive, not breathing, and without a pulse. Resuscitative efforts were initiated, and EMS was called, but the resident was pronounced deceased at the facility. During the code, a blood glucose check revealed a critically low reading. Interviews and record reviews confirmed that staff failed to follow facility policy regarding timely reporting and assessment of changes in condition, as well as routine rounding and verification of blood glucose readings, directly contributing to the resident's lack of care and subsequent death.