Failure to Notify Physician of Repeated Blood Glucose Monitoring Refusals
Penalty
Summary
Facility staff failed to notify a resident's physician of multiple refusals to allow blood glucose (accu check) monitoring on four separate occasions. The resident, who had diagnoses including type 2 diabetes mellitus, Alzheimer's disease, and dementia, was admitted and readmitted with a care plan indicating a history of refusing treatment and instructions to notify the physician after three refusals. Despite documentation of refusals on the Medication Administration Record, staff did not inform the physician as required by both the care plan and facility policy. Interviews with nursing staff and the Quality Assurance Nurse confirmed that the physician was not notified of the resident's refusals to undergo accu checks on the specified dates. The facility's policy required timely physician notification of treatment refusals, especially when there could be serious consequences. The failure to notify the physician was verified through record review and staff interviews.