Failure to Implement Hypoglycemia Protocol and Notify Physician
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with diabetes by not implementing its hypoglycemia protocol and not notifying the physician in a timely manner following a significant change in the resident's condition. Specifically, the resident, who had diagnoses including diabetes, high blood pressure, and cerebral infarction, was found to have a blood glucose level of 45 mg/dL, which is below the threshold requiring intervention according to facility policy. The resident was also under physician orders to notify the provider if blood glucose was less than 60 mg/dL and was NPO (nothing by mouth). Despite these findings, there was no documentation in the resident's clinical record regarding the hypoglycemic episode, no assessment of the event, no evidence of physician notification, and no record of interventions taken to address the low blood glucose. Staff interviews confirmed the absence of documentation and the failure to follow the hypoglycemia protocol as required by facility policy and physician orders.