Failure to Notify Physician of Critically High Blood Glucose Level
Penalty
Summary
The facility failed to notify a physician of a significant change in a resident's blood glucose levels, as required by their own procedures. According to the facility's procedure guide, staff are to report any blood glucose levels greater than 300 mg/dl or less than 70 mg/dl to the resident's physician. A review of the medical record for a resident with diagnoses including type two diabetes mellitus and Alzheimer's disease showed that the resident had blood glucose readings of 429 mg/dl and 561 mg/dl on two separate occasions. While documentation confirmed that the physician was notified and orders were received for the first high reading, there was no documentation that the physician was notified for the second, even higher, reading. Interviews with nursing staff and facility leadership confirmed that the expectation was for the physician to be notified of blood glucose levels over 400 mg/dl. The Director of Health Services also noted that the physician order was missing specific parameters for when to notify the physician. The lack of documentation and notification for the second high blood glucose reading constituted a failure to follow the facility's procedures and physician notification requirements for significant changes in a resident's condition.