Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify physicians of significantly elevated capillary blood glucose (CBG) levels for a resident with diabetes and heart failure. According to facility policy, licensed nurses are required to report abnormal laboratory values, including changes in blood glucose, to the physician or advanced practice provider. The resident's care plan specifically directed staff to monitor for signs and symptoms of hyperglycemia or hypoglycemia and to report abnormal findings to the physician. A physician order was in place instructing staff to call the physician if the resident's blood sugar exceeded 500 mg/dL. Despite these directives, the clinical record showed multiple instances where the resident's blood sugar readings were at or above 500 mg/dL, with no documentation that the provider was notified. This was confirmed by the DON and the Nursing Home Administrator during interviews. The failure to notify the physician of these abnormal blood glucose levels constituted a violation of facility policy and state regulations regarding resident care and physician notification.