Failure to Timely Assess Blood Glucose as Ordered
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident received treatment and care in accordance with physician orders and professional standards of practice. Specifically, a resident with diagnoses including end stage renal disease, type 2 diabetes mellitus, mild protein-calorie malnutrition, and dependence on renal dialysis had a physician order for Novolog (insulin Aspart) to be administered per sliding scale before meals and at bedtime, with blood glucose checks scheduled at 7:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. Review of the clinical record and electronic medication administration record (e-TAR) revealed no documented evidence that the resident's blood glucose level was assessed at 7:30 a.m. as ordered. On the morning in question, nursing notes indicated that the resident was found unresponsive, unable to swallow, and had a critically low blood sugar reading of 31. Emergency interventions were initiated, including administration of intramuscular glucagon, but the resident's blood sugar remained low. The resident was subsequently transferred to the hospital for further evaluation. Documentation indicated that the blood glucose level was not obtained at the scheduled time due to hospitalization, but records show the resident was not picked up by emergency personnel until later that morning, confirming the missed assessment.