Failure to Monitor Diabetic Resident for Hypo/Hyperglycemia Symptoms
Penalty
Summary
The facility failed to monitor a resident with a history of diabetes mellitus, including diabetic ketoacidosis and hyperglycemia, for signs and symptoms of hypoglycemia and hyperglycemia, despite physician orders and care plan interventions. The resident had documented refusals of blood sugar checks and insulin, and the care plan specifically directed staff to monitor for symptoms of blood sugar abnormalities. However, there was no documentation in the progress notes or other records indicating that staff monitored the resident for these symptoms, even when blood sugar checks were refused. Physician orders required blood sugar monitoring before meals and at bedtime, with insulin administration per sliding scale, and included protocols for managing hypoglycemia. Despite these orders, the resident's blood sugar was not checked at required times, and there was no evidence of staff monitoring for clinical signs of hypo- or hyperglycemia. The resident was later found in cardiac arrest with a critically high blood sugar level, and staff interviews confirmed the lack of monitoring and documentation for symptoms related to blood sugar abnormalities.