Failure to Notify Physician of Out-of-Range Blood Sugar Values
Penalty
Summary
The facility failed to notify the physician as required when a resident's blood sugar (BS) values were outside the parameters specified in the physician's orders. The resident in question had diagnoses including diabetes mellitus type II, dementia, and exocrine pancreatic insufficiency, and was receiving insulin therapy. The physician's order directed staff to hold insulin for BS less than 110 and to call the physician for BS less than 70 or greater than 400. However, review of the clinical record and electronic Medication Administration Record (eMAR) revealed multiple instances where the resident's BS readings were either below 70 or above 400, but there was no documentation that the physician was notified as required. Additionally, there were occasions where insulin was administered despite BS values being below the ordered threshold, again without documented physician notification. During interviews, facility staff confirmed that there was no documentation of physician notification for these out-of-range BS values, and the facility's policy required such notifications to be documented, including the time, method, and response. The lack of documentation and failure to follow physician orders for notification constituted the deficiency. The report specifically notes that all physician notifications should be recorded in the clinical record and that the physician's orders were not followed in these instances.