Failure to Document Physician Notification for High Blood Glucose Levels
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with multiple complex diagnoses, including type 2 diabetes with ketoacidosis, sepsis, and metabolic encephalopathy. Over a period of five days, the resident experienced consistently high blood glucose levels, with readings above 200 mg/dL and reaching as high as 337 mg/dL. Despite these abnormal results, there was no documentation by the nursing staff (RN B and LVN C) indicating that the physician was notified or that any recommendations from the physician were received or implemented. The resident was not prescribed insulin and was only receiving oral antidiabetic medication. Review of the resident's care plan and physician orders confirmed that staff were expected to monitor for abnormal blood glucose levels, report them to the physician, and document any interventions or physician communications. However, nursing progress notes contained no entries regarding the high blood glucose levels during the period in question. Interviews with nursing staff and the DON revealed that while staff claimed to have notified the physician, this was not documented in the medical record. The DON acknowledged that best practice would be to write a note, and the facility's policy required documentation of physician notifications and orders. The lack of documentation regarding physician notification and response for the resident's elevated blood glucose levels was confirmed through record review and staff interviews. The physician stated he was always notified of high blood glucose readings, but there was no evidence of this in the clinical record. The facility's policy on following physician orders required that all such communications and interventions be documented, which was not done in this case.