Failure to Notify Physicians and Assess for Diabetic Emergencies
Penalty
Summary
The facility failed to notify physicians of elevated or decreased capillary blood glucose (CBG) levels and did not assess residents for hyperglycemia and hypoglycemia, resulting in immediate jeopardy for six residents. Facility policy required staff to report complications such as hypoglycemia and to notify providers of significant changes in blood glucose levels, but multiple instances were found where blood sugar values outside of ordered parameters were not communicated to physicians or followed up on. For example, one resident had numerous blood glucose readings above 400 mg/dL over several months without documentation of physician notification or follow-up, despite physician orders to notify for values above 400 mg/dL. Another resident experienced a severe hypoglycemic event, with a blood sugar of 31 mg/dL, and was transferred to the hospital, but there was no evidence of timely intervention or notification as required by policy and physician orders. Several other residents with diabetes had repeated episodes of blood glucose levels outside of the parameters set by their physicians, with no documentation of notification or follow-up. These included blood glucose readings both above and below the thresholds that should have triggered immediate action according to facility policy and physician orders. In some cases, residents were admitted to the hospital for complications related to hyperglycemia or hypoglycemia, and documentation showed that staff failed to recognize or respond to these acute changes in condition as required. The facility's own policies, as well as manufacturer instructions for glucometers and insulin, outlined clear procedures for monitoring, documenting, and responding to abnormal blood glucose levels. However, review of clinical records, staff interviews, and policy documents revealed that these procedures were not consistently followed. The failure to notify physicians and assess residents for acute diabetic complications directly contributed to adverse outcomes and placed residents in immediate jeopardy.