Failure to Notify Physician and Family of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the notification of physicians and responsible parties about critical blood glucose levels for two residents with diabetes. For one resident, multiple instances of critically high blood glucose readings were recorded in the Medication Administration Record, but there was no documentation in the nurse's notes or electronic medical record that the physician or family were notified, as required by the care plan. The Director of Nursing confirmed that there was no evidence of notification for these critical values. For another resident with diabetes and hyperglycemia, critical blood glucose levels were also documented, and while insulin was administered per a nurse practitioner's order, there was no documentation that the family was notified of the change in condition. Additionally, the nurse practitioner was not notified of all critical values as required. The facility's guidelines specify that significant changes in a resident's condition, such as critical lab values, must be immediately reported to the physician and responsible party, and all notifications and new orders must be documented in the medical record. These requirements were not met for the residents reviewed.