Failure to Assess and Respond to Resident's Change in Condition Resulting in Severe Hypoglycemia
Penalty
Summary
A resident with a history of type 2 diabetes mellitus, chronic obstructive pulmonary disease, and a major contusion of the left kidney experienced a significant change in condition during the night. The resident was observed by staff to be highly disoriented, kicking, and mumbling incoherently. The resident's oxygen saturation was found to be low, and after the nasal cannula was reapplied, the oxygen level improved, but the resident continued to display altered mental status and slurred speech. Despite these symptoms, the nursing staff did not perform or document a blood glucose check during the episode, even though the resident was diabetic and experiencing acute neurological symptoms. The resident repeatedly called 911 for help, and a police officer responded to the facility but was informed by staff that the resident was fine. The resident's family was also contacted by the resident and, upon hearing his slurred speech, called 911 out of concern for a possible stroke. When EMS arrived, the resident was transported to the hospital, where he was found to have severe hypoglycemia with a blood glucose level of 24 mg/dl. Hospital records indicated that the resident had symptoms consistent with hypoglycemia, including slurred speech, right-sided facial droop, and weakness, which improved after administration of dextrose. Interviews with facility staff revealed that the LPN and CNA on duty noted the resident's abnormal behavior and vital signs but did not recognize or appropriately respond to the change in condition. The LPN reported the resident's improvement to the physician and DON, but this was based on comparison to the initial episode rather than the resident's baseline. The physician was not informed of the resident's ongoing speech difficulties, and the facility's documentation and investigation focused on communication issues rather than the clinical response to the resident's acute change in condition. Facility policy required detailed assessment and reporting of acute changes, but this was not followed in the resident's case.