Failure to Provide Timely Hypoglycemia Management and Notification
Penalty
Summary
The facility failed to provide person-centered care and adhere to professional standards of practice for diabetes management for one resident with severe cognitive impairment and a diagnosis of diabetes. The resident had physician orders for insulin administration based on blood glucose levels, with specific instructions to notify the physician and RN supervisor if blood glucose was less than 70 mg/dL, and to treat hypoglycemia promptly with 15 to 20 grams of fast-acting carbohydrates. On the date in question, the resident's blood glucose was recorded at 54 mg/dL, and the scheduled insulin dose was held as per orders. Despite the low blood glucose reading, there was no documented evidence that the resident received orange juice or any other carbohydrate in a timely manner as required by the hypoglycemic protocol. Additionally, there was no documentation that the RN supervisor or physician were notified of the hypoglycemic event until after the resident experienced a fall from their wheelchair and was found to be lethargic but responsive. The lack of timely intervention and notification was confirmed by the Nursing Home Administrator, and the documentation did not reflect adherence to the facility's policy or physician orders regarding hypoglycemia management.