Failure to Assess and Intervene for Severe Hypoglycemia
Penalty
Summary
A resident with a history of diabetes, heart failure, renal insufficiency, and other complex conditions experienced a severe hypoglycemic event due to the facility's failure to appropriately assess and intervene. The resident was prescribed multiple diabetic medications, including insulin and Tirzepatide, with scheduled blood glucose checks and medication administration times. On the day of the incident, the scheduled 4:00 PM blood sugar check and administration of insulin and Tirzepatide were not completed within the required window. The nurse coming on duty was informed of the missed tasks but did not immediately assess the resident or complete the overdue interventions. The resident was later found unresponsive by a family member, and a blood sugar check revealed a critically low level of 27 mg/dl. Facility staff failed to follow established protocols for hypoglycemia management. The nurse did not administer a carbohydrate source or call the primary care physician when the resident was found unresponsive with low blood sugar. Additionally, there was no Glucagon available in the medication carts, and the resident did not have an order for Glucagon prior to the event. The nurse spent approximately 15 minutes searching for Glucagon instead of providing immediate intervention, and did not call emergency services as requested by the family. The family member ultimately called 911, and emergency responders administered Glucagon, after which the resident became responsive and was transported to the hospital. Review of the resident's records revealed previous episodes of low blood sugar that were not properly documented or addressed according to facility policy. There was a lack of documentation regarding interventions taken to correct hypoglycemia on multiple occasions, and vital signs were not recorded at the time the resident was found unresponsive. Staff interviews confirmed that the required steps for hypoglycemia management, including timely administration of carbohydrates, notification of the physician, and documentation, were not consistently followed.