Failure to Notify Providers and Administer Diabetic Medications Resulting in Critical Hyperglycemia and Resident Death
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including diabetes, heart failure, chronic kidney disease, and who was under hospice care, was admitted for respite care. The resident was prescribed Metformin twice daily, long-acting insulin at bedtime, and potassium chloride. The care plan did not include diabetes management, despite active orders for diabetic medications. Over several days, the resident's blood sugar (BS) levels were found to be critically high (576 and over 600 on multiple occasions), but there was no documented evidence that the physician or hospice provider was notified of these elevated readings. Additionally, the resident missed two dayshift doses of Metformin and one dose of potassium chloride due to medication unavailability, with no evidence that the pharmacy, physician, or hospice was contacted to obtain the medications or that the resident's BS levels were checked during these times. On the morning of a fall, the resident was found on the floor with a head injury. The nurse assessed the resident, provided basic first aid, and noted that the resident was able to eat breakfast afterward. However, there was no documentation of a blood sugar check following the fall, despite the resident's diabetic status and the incident involving a head injury. Later, the resident exhibited a change in condition, including seizure-like activity and unresponsiveness. Attempts to contact the family member and hospice provider were initially unsuccessful. When the hospice nurse arrived, the resident was found to have a large hematoma, unresponsive pupils, and low blood pressure, and was subsequently sent to the hospital. Hospital records indicated the resident was admitted in critical condition with a subarachnoid hemorrhage, hypotension, and a blood sugar level of 812. The resident was diagnosed with hyperosmolar hyperglycemic syndrome, cardiogenic shock, and ultimately passed away. Interviews with facility staff revealed a lack of awareness regarding the resident's missed medications and high blood sugar levels, as well as failures in communication and documentation. Staff acknowledged that elevated BS levels should have prompted immediate notification of the physician or hospice provider and that missed doses of diabetic medication could have serious consequences. There was also confusion regarding the process for obtaining unavailable medications and the responsibilities for diabetic management in hospice patients.