Failure to Identify and Treat Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to identify, assess, monitor, and follow physician orders for signs and symptoms of hypoglycemia in a resident with diabetes, resulting in an immediate jeopardy situation. The resident, who had a diagnosis of diabetes mellitus and rhabdomyolysis, experienced multiple episodes of low blood sugar that were not properly addressed according to physician orders and facility protocols. Blood glucose levels were not consistently monitored, and there was a lack of timely intervention and notification to the provider when hypoglycemia was identified. On the day of the incident, the resident's blood sugar was recorded as 81 in the morning, and diabetes medications were administered. Later in the day, the resident's blood sugar dropped to 54, but there was no documented assessment for hypoglycemia symptoms, no recheck of blood sugar after a meal, and no notification to the physician. Despite a further drop in blood sugar to 39, the required interventions, including administration of glucagon and continuous monitoring, were inconsistently documented and not all actions were taken as ordered. The resident continued to receive diabetes medications without appropriate blood sugar checks, and staff failed to notify the provider or reassess the resident as required. Interviews with nursing staff revealed a lack of education and understanding regarding diabetic monitoring and hypoglycemia management. Staff did not follow hypoglycemic protocols, did not consistently document interventions, and failed to notify the provider in a timely manner. The resident ultimately became lethargic and was transferred to the emergency department, where a critically low blood sugar was confirmed, requiring intensive treatment. The facility's own policies and physician orders for hypoglycemia management were not followed throughout the incident.
Removal Plan
- Educated licensed nursing staff and agency staff about diabetic management of hypoglycemia and hyperglycemia monitoring, assessing, treatments, physician notification and standards of documentation with competency testing.
- Reviewed all residents with diagnosis of diabetes to ensure blood glucose levels were within range, had diabetic protocols in place, care plans were accurate and provider orders were followed.
- Reviewed facility Diabetic Monitoring and Change of Condition policies for accuracy.