Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify and consult with a resident's physician after significant changes in the resident's condition. Specifically, a resident with type 2 diabetes mellitus had blood glucose readings above the ordered parameter of 350 on two occasions. The physician's orders clearly stated that if blood sugar was greater than 350, the nurse should administer 5 units of insulin and call the medical doctor. Despite this, there was no documentation in the resident's progress notes indicating that the physician had been contacted regarding these elevated blood sugar levels. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for the physician to be notified and for this notification to be charted each time the blood sugar exceeded the specified threshold. Review of the resident's records showed no such documentation at the time of the events. A late entry was made the following day, indicating that the provider was informed of the previous day's elevated readings, but this was not done immediately as required by the physician's orders and facility policy.