Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify a resident's physician of multiple elevated blood glucose levels, as required by both physician orders and facility policy. The resident in question was documented as severely cognitively impaired and had a physician order for blood glucose monitoring twice daily. Despite repeated blood glucose readings above 200 mg/dl, there was no evidence in the electronic medical record that the physician was notified of these elevated results. The medication administration record showed numerous instances where the resident's blood glucose exceeded the reporting threshold, with values ranging from 206 mg/dl to 350 mg/dl over several days. Interviews with facility staff, including the Director of Nursing and a Nurse Practitioner, confirmed that the facility's policy required staff to report any blood glucose readings above 200 mg/dl. Both staff members acknowledged that the elevated readings should have been reported to the physician, but this did not occur. The facility's policy on blood glucose monitoring, revised in June 2023, also specified that such results must be communicated to the physician or according to physician-ordered parameters.