Failure to Follow Physician Orders and Notify Provider for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident with brittle diabetes received care and treatment in accordance with professional standards of practice. The resident had multiple physician orders for blood glucose monitoring, insulin administration, and hypoglycemia management, as well as care plans specifying the need for strict adherence to these orders and prompt provider notification in the event of medication refusal or abnormal blood glucose levels. Despite these directives, the resident frequently refused prescribed doses of insulin, and staff administered alternate doses without provider authorization. There was no documentation that the provider was notified of these refusals or of the administration of doses outside of the ordered parameters. Additionally, the resident experienced multiple episodes of both hypoglycemia and hyperglycemia, with blood glucose readings falling below 70 mg/dL and rising above 400 mg/dL on several occasions. Facility policy required immediate provider notification and specific interventions in these situations, but the medical record lacked evidence that these steps were consistently taken. In several instances, glucose tablets were administered in doses different from those ordered, and there was no documentation of provider notification or follow-up blood glucose checks as required by policy. The MAR also showed that staff did not always document follow-up actions or provider communication after abnormal blood glucose readings or medication refusals. Interviews with nursing staff and facility leadership confirmed that staff were not consistently following provider orders or facility policy regarding medication administration and provider notification. Nurses reported administering insulin and glucose tablets in amounts requested by the resident rather than as ordered, and they did not routinely notify the provider of refusals or abnormal blood glucose levels. The DON and CEO acknowledged that staff were expected to follow provider orders and communicate changes in the resident's condition, but this was not consistently occurring in practice.