Failure to Notify Physician of Critically Elevated Blood Glucose
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with diabetes mellitus. The resident had physician orders and a care plan that required notification of the primary care provider (PCP) if blood glucose levels exceeded 401 mg/dL. On 6/9/2025, the resident's blood sugar was recorded at 403 mg/dL by an LVN, who administered the prescribed insulin dose but did not notify the PCP as required by both the care plan and physician orders. There was no documentation in the nursing notes or 24-hour report binder indicating that the PCP was notified of the elevated blood sugar level. Interviews revealed that the DON was unaware of the incident until after the fact and confirmed that the PCP should have been notified immediately. The LVN involved stated she was new and had not fully read the order, resulting in the failure to notify the PCP. The PCP confirmed he was not notified and would have provided further instructions if contacted. The facility's policy required prompt notification of the physician for changes in a resident's condition, including specific instructions to notify the physician, which was not followed in this case.