Failure to Notify Physicians and Document Blood Glucose Management
Penalty
Summary
The facility failed to ensure that staff consistently notified physicians when residents' blood glucose levels exceeded the parameters ordered by the physician or those outlined in facility policy. In several instances, staff did not document blood glucose levels on the Medication Administration Record (MAR) or provide explanations when using codes such as NA (not administered), NI (no insulin required), or HD (hold) on the MAR. This deficiency was identified among four residents sampled from a group of forty-eight who required routine blood glucose monitoring. For one resident with a history of diabetes, high blood pressure, renal disease, and stroke, there were multiple occasions where blood glucose readings were either critically low or high, but there was no documentation that the physician was notified as required by the physician's orders. Additionally, there were instances where insulin was not administered as ordered, and no explanation or blood glucose level was documented. Similar issues were observed with other residents, including missing documentation for blood glucose levels, lack of physician notification when levels were outside of ordered parameters, and unexplained use of MAR codes indicating insulin was not given or held. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to notify physicians when blood glucose levels were outside of specified parameters and to document these notifications and any reasons for not administering insulin in the progress notes. Despite inservices and reminders, the problem persisted, with staff failing to follow protocols for physician notification and documentation, as evidenced by the review of records and staff interviews.