Failure to Notify Physician of Resident's Change in Condition and Elevated Blood Glucose
Penalty
Summary
The facility failed to ensure timely physician notification of a change in condition for a resident with diabetes and non-Alzheimer's dementia. After returning from the hospital, all of the resident's diabetes medications and blood glucose monitoring were discontinued per new orders, but there was no evidence that the primary physician was notified of these changes. Subsequently, the resident exhibited symptoms of hyperglycemia, including polyuria, polydipsia, and polyphagia, with blood glucose readings as high as 567. Despite these critical findings, there was a delay in notifying the physician, and interventions were not promptly implemented. Staff interviews revealed that the nurse relied on faxing the physician rather than calling, even though the facility had emergency insulin available and the policy expected a call for urgent changes in condition. Further interviews with facility leadership and the resident's physician confirmed that the physician was not notified of the discontinuation of diabetes management or the elevated blood glucose levels. The physician stated she would have expected to be called if the blood glucose exceeded 400, and that there was always an on-call physician available. The facility's policy recommended provider notification for blood sugars less than 70 or greater than 350, but this was not followed in the resident's case.