Failure to Timely Assess and Communicate Acute Change in Condition for Diabetic Resident
Penalty
Summary
The facility failed to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with type 2 diabetes, resulting in actual harm and subsequent hospitalization. The resident had a history of heart disease, heart failure, muscle weakness, cognitive communication deficit, muscle wasting, hemiplegia, hemiparesis, vascular disease, and diabetes. Physician orders required monitoring for signs and symptoms of hypo/hyperglycemia, with instructions to notify the provider if blood sugar was under 60 or over 400 mg/dL. Despite these orders, a blood glucose reading of 471 mg/dL was recorded and not communicated to the medical provider, and there was no documentation of assessment or intervention for this critical value. Over several days, the resident exhibited symptoms of hyperglycemia, including changes in mental status, drowsiness, incontinence, and dietary changes, which were reported by CNAs to nursing staff. However, there was a lack of comprehensive assessment and timely communication with the medical provider regarding these changes. On the day of hospital transfer, the resident was found to have extremely high blood glucose readings (over 500 mg/dL), and only after this point did staff begin to treat the hyperglycemia with insulin. Multiple doses of insulin were administered with no significant improvement, and the resident's condition continued to deteriorate until the family demanded hospital transfer. Upon hospital admission, the resident was diagnosed with diabetic ketoacidosis (DKA), acute metabolic encephalopathy, and acute kidney injury, with a blood glucose reading of 1157 mg/dL. Interviews with staff revealed that changes in the resident's condition were observed and reported by CNAs, but nursing staff did not consistently assess or document these changes, nor did they notify the medical provider as required by policy and physician orders. The facility's policies on notification of change in condition and blood glucose monitoring emphasized prompt provider notification and documentation, but these were not followed. The DON confirmed that the medical team should have been notified of the high blood sugar readings and that more frequent monitoring and interventions should have been implemented given the resident's trending lab results and dietary issues.