Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition as required by physician orders and facility policy. Specifically, the resident had multiple blood glucose readings significantly above the ordered threshold of 200 mg/dL over several consecutive days. Despite the physician order to notify for blood sugars greater than 200 mg/dL, there was no documentation that the physician was informed of these elevated results. Interviews with nursing staff confirmed that notifications were either not made or not documented, and one nurse was unaware of the notification requirement in the physician's order. The Director of Nursing also confirmed the lack of documentation and acknowledged that the physician should have been notified immediately when the resident's blood sugar exceeded the specified limit. As a result of the failure to notify the physician, the resident experienced a significant decline, presenting with symptoms such as a deep chest cough, elevated pulse, and high fever, which led to a transfer to the hospital. Upon admission, the resident was diagnosed with severe hyperglycemia, dehydration, and hypernatremia, with critical lab values indicating a life-threatening condition. The facility's own policies required staff to incorporate physician notification parameters into care planning and to notify the physician of changes in the resident's condition, but these procedures were not followed in this case.