Failure to Notify Physician of Abnormal Glucose Readings
Penalty
Summary
The facility failed to notify a physician of abnormal blood glucose readings for a resident with diabetes, as required by physician orders and facility policy. The resident had multiple documented blood glucose levels exceeding 400 mg/dL, which, according to the physician's sliding scale insulin order, required immediate notification of the physician or CRNP. Despite these elevated readings occurring on several occasions, there was no evidence in the resident's progress notes that the physician was notified as directed. The resident in question had a medical history including diabetes, anemia, and hypertension, and was receiving insulin therapy with specific parameters for monitoring and reporting abnormal glucose levels. The facility's policy and the resident's care plan both emphasized the importance of maintaining blood glucose within the desired range and following physician orders for reporting. Staff interviews confirmed that the required notifications were not made, resulting in a failure to provide care and treatment according to orders and the resident's clinical needs.