Failure to Provide Required Transfer Documentation and Bed-Hold Notification
Penalty
Summary
A resident with a history of diabetes mellitus, hyperglycemia, and a pancreatectomy experienced a significant increase in blood glucose levels, as indicated by their Dexcom device. The resident reported a blood sugar reading above 400 mg/dL to the assigned LPN during the evening, but was told that blood sugar checks were only scheduled before meals and not after 5:00 PM. Despite repeated requests, the LPN initially refused to check the resident's blood sugar, eventually relenting after multiple requests and confirming a high reading in the 300s. The resident, feeling their concerns were not addressed, contacted their representative and subsequently called 911 for emergency assistance. When EMTs arrived, they requested standard transfer documentation from the LPN, including the resident's medical history, current medications, allergies, and recent medication administration records. The LPN declined to provide any documentation, stating that the facility was not responsible for the transfer since the resident initiated the 911 call. The EMTs transported the resident to the emergency department, where a blood glucose reading of 563 mg/dL was recorded and the resident received treatment for severe hyperglycemia. The emergency department provided discharge instructions and new physician orders, which were hand-delivered to the LPN upon the resident's return to the facility. Upon review, there was no documentation in the resident's medical record regarding the transfer to the hospital, the information provided to the EMTs, or the receipt and implementation of new physician orders from the hospital. The facility also failed to provide the required written information to the resident or their representative regarding the facility's bed-hold policy prior to the transfer. Additionally, there was no evidence that the resident's physician was notified of the change in condition or the hospital visit, and no documentation of actions taken by the DON or LPN upon the resident's return.