Failure to Document Physician Notification for Elevated Blood Sugar
Penalty
Summary
The facility failed to maintain accurate and complete documentation regarding physician notification for one resident. According to facility policy, the medical record should include care-specific details, such as notification of the physician when indicated. For a resident with Alzheimer's disease, diabetes, and high blood pressure, there was a physician's order requiring notification if blood sugar (BS) results exceeded 401 mg/dL. The resident's Medication Administration Record (MAR) showed multiple instances where BS readings were above this threshold. Despite these elevated BS readings, the clinical record did not contain evidence that the physician was notified as required by the order. During an interview, the Nursing Home Administrator confirmed that while staff may text physicians using a supervisor's phone, these communications are not included in the resident's permanent clinical record. As a result, there was no documentation in the clinical record to verify that the physician was notified in accordance with the physician's orders.