Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to follow physician directives regarding blood glucose (BG) monitoring and notification for a resident with diabetes mellitus and severe cognitive impairment. The resident had orders to notify the physician if BG levels were less than 60 or greater than 400. Despite multiple BG readings significantly above 400, documentation shows that staff often faxed notifications to the provider rather than calling, resulting in delayed communication. There were also extended periods without documented follow-up or action after high BG readings, including intervals of over 12 hours between checks and notifications. The resident experienced repeated episodes of severe hyperglycemia, with BG values as high as 590, and exhibited symptoms such as confusion, lethargy, and weakness. Staff interviews revealed confusion about notification protocols, especially during weekends and after hours, with some nurses unsure of which provider to contact or relying on fax rather than direct communication. The nurse practitioner confirmed that faxes sent over the weekend were not received until the following week, and expected that nurses would call the on-call doctor for BG levels outside parameters. Clinical records and staff statements indicate that the lack of timely physician notification and follow-up contributed to the resident's deterioration, ultimately resulting in hospitalization for severe hyperglycemia. The documentation also showed that staff were not consistently oriented to emergency notification procedures, and there was a lack of immediate action in response to critical BG values as required by the physician's orders.