Failure to Notify Responsible Party and Document Change in Condition for Resident with Critically High Blood Sugar
Penalty
Summary
The facility failed to follow its policy and procedure regarding changes in a resident's condition or status by not informing a resident's responsible party when the resident experienced a critically high blood sugar level of 480 and required an additional dose of insulin. The responsible party was not notified of this significant change, despite the resident lacking the mental capacity to make medical decisions and being dependent on staff for most activities of daily living. The facility's policy required notification of the resident's representative in such circumstances. Additionally, the facility did not document the resident's blood sugar level of 480 in the medical record, nor did staff complete an SBAR Communication Form or a Change of Condition note as required by facility policy. The Director of Nursing confirmed that there was no documentation of the event, no SBAR form, and no notification to the responsible party in the resident's record. These omissions were identified during a review of the resident's records and interviews with facility staff.