Failure to Prevent Neglect and Respond to Critical Hyperglycemia
Penalty
Summary
A resident with a history of diabetes mellitus, hyperglycemia, and a prior pancreatectomy experienced a critical episode of elevated blood sugar while under the care of facility staff. The resident utilized a Dexcom continuous glucose monitor, which indicated a blood sugar reading above 400 mg/dL. Despite repeatedly informing the assigned LPN of the dangerously high glucose readings and associated symptoms such as headache, blurry vision, nausea, and mental confusion, the LPN initially refused to check the resident's blood sugar outside of scheduled times and dismissed the resident's concerns, instructing them to "go sleep it off." The resident continued to request assistance, including asking for a blood sugar check and for the physician to be contacted for insulin orders. The LPN eventually checked the blood sugar, which was found to be in the high 300s, but still did not contact the physician, provide insulin, or initiate further interventions. The LPN also refused to facilitate a transfer to the hospital, stating there were no orders for insulin or glucose checks after a certain time. The resident, after consulting with their representative, called 911 independently. Emergency Medical Technicians (EMTs) responded, confirmed the resident's symptoms and high glucose readings, and transported the resident to the emergency department, where a blood sugar of 563 mg/dL was documented and immediate treatment was provided. Facility leadership later confirmed that the LPN did not follow professional standards or facility policy, as there was no documentation of a change in condition, no physician notification, and no transfer documentation provided to the EMTs. Additionally, upon the resident's return from the hospital, new physician orders and discharge instructions were not entered into the medical record or implemented, and there was no documentation that the resident's physician was notified of the emergency event or the new orders.