Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to immediately notify a resident's physician when blood glucose readings exceeded the physician-ordered parameters. Specifically, a male resident with diagnoses including heart failure, type 2 diabetes, and chronic kidney disease had blood sugar readings of 386 mg/dL and 400 mg/dL on the same morning, both above the threshold of 350 mg/dL that required physician notification according to the resident's orders. The resident did not receive his scheduled morning dose of insulin Lispro before breakfast because the medication was not available until later in the morning. Despite these elevated readings and the missed insulin dose, there was no documentation that the physician was notified as required. Interviews with facility staff, including the LVN who documented the readings, the Staff Development Coordinator, the ADON, and the DON, confirmed that the physician should have been notified immediately upon obtaining blood sugar results outside the ordered parameters. The facility's own protocol also required immediate intervention and physician notification for blood glucose levels greater than 350 mg/dL. The lack of timely notification was acknowledged by staff and was not in accordance with physician orders or facility policy.