Failure to Address Critical Blood Glucose Levels and Follow Diabetes Management Protocols
Penalty
Summary
The facility failed to follow its own policies and procedures regarding blood glucose monitoring and management for two residents with diabetes, resulting in critical blood glucose levels not being addressed appropriately. For one resident, who had diagnoses including morbid obesity and type II diabetes mellitus, care plan interventions required monitoring blood sugars as ordered, administering insulin per sliding scale, and reporting abnormal blood sugars to the physician. However, the physician orders did not include sliding scale insulin or parameters for physician notification, and staff failed to obtain these orders. Over the course of a month, this resident experienced multiple episodes of critically high blood glucose levels (ranging from 413 to 500) without evidence of physician notification or intervention, and documentation of these events was missing from the nurse's notes. Another resident with diabetes and hyperglycemia had physician orders for both scheduled and sliding scale insulin, but the sliding scale only covered blood glucose levels up to 399. On one occasion, this resident's blood glucose was recorded at 486 and later at 400, but insulin was not administered as ordered within the regulatory time frame, and the sliding scale was not followed for values above 399. Documentation was inconsistent, and there was no evidence that the physician was notified of the critical blood glucose levels at the required times. The facility's policy required immediate physician notification and documentation for blood glucose levels above 400, but this was not done. Interviews with staff, including the DON and Medical Director, confirmed that staff did not consistently follow physician orders, care plan interventions, or facility policy regarding blood glucose monitoring, insulin administration, and physician notification. The failures included not obtaining necessary physician orders, not administering or documenting medication within regulatory requirements, and not ensuring that critical blood glucose levels were addressed by a physician or nurse practitioner. These deficiencies resulted in prolonged periods of uncontrolled hyperglycemia for both residents.