Failure to Follow Physician's Orders for Blood Glucose Monitoring and Catheter Use
Penalty
Summary
The facility failed to follow professional standards of practice by not adhering to physician's orders for three residents. For one resident with diabetes, there was a physician's order to check blood glucose levels for hypoglycemic or hyperglycemic symptoms and to follow a specific hypoglycemic protocol if blood glucose was less than 70 mg/dL. The resident's medical record showed a blood glucose reading of 50 mg/dL, but staff did not retake the blood glucose 15 minutes later as required by the protocol. A staff member confirmed that the hypoglycemic protocol was not followed in this instance. Another resident with multiple diagnoses, including amyotrophic lateral sclerosis and respiratory failure, was observed to have a urinary catheter on several occasions. However, a review of the resident's physician's orders did not show any order for a urinary catheter. The Acting DON stated that the physician's orders were not updated upon the resident's readmission due to multiple admissions and unforeseen circumstances, resulting in the resident having a catheter without a corresponding physician's order.