Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
Facility staff failed to notify a physician when a resident's blood glucose levels exceeded the parameters set by the physician's order. The order specified that the physician should be notified if the resident's blood glucose was greater than 200. Despite this, clinical record review showed multiple instances in June 2025 where the resident's blood sugar readings were above 200, but there was no documentation of physician notification. Specific dates and times were identified where blood glucose levels ranged from 250 to 462, and no corresponding physician notification was found in the medical record. During staff interviews, a unit manager (LPN) confirmed that the physician should have been notified according to the order and acknowledged that the nurse did not follow the required notification protocol. The facility's policy on changes in a resident's condition also requires prompt physician notification of significant changes. The deficiency was confirmed through review of clinical records, medication administration records, and staff interviews, with no additional information provided prior to the survey exit.