Failure to Provide Timely Diabetes Management and Physician Notification
Penalty
Summary
A deficiency was identified in the facility's management of a resident with diabetes mellitus and non-Alzheimer's dementia. Upon admission, the resident was to have a continuous glucose monitor (CGM) to avoid frequent fingerstick blood sugar checks, but there was no evidence that a CGM was ever implemented. The resident's diabetes medications and blood glucose monitoring were discontinued following a hospital visit, with no documentation that the primary physician was notified of these changes. After returning from the hospital, the resident exhibited symptoms of hyperglycemia, including polyuria, polydipsia, and polyphagia, and had extremely elevated blood glucose readings (over 500 mg/dL), but there was no immediate intervention or timely physician notification as required by facility policy and physician expectations. Nursing staff failed to follow established protocols for notifying the physician when the resident's blood glucose exceeded the recommended parameters. Instead of calling, staff relied on fax communication, which delayed the response. Interviews with facility leadership confirmed that the expectation was for nurses to call the physician in cases of significant changes in condition or abnormal blood glucose levels, but this did not occur. Additionally, the facility had insulin available in the emergency kit, but the nurse did not administer it or contact the physician directly, citing a lack of available insulin, which was contradicted by the emergency kit inventory. The resident's physician was not informed of the discontinuation of diabetes medications and monitoring, nor of the subsequent hyperglycemic episodes. The physician stated she would have expected to be notified of blood glucose levels greater than 400 mg/dL and clarified that there was always an on-call physician available. The facility's policy also specified provider notification for blood sugar levels less than 70 or greater than 350 mg/dL, but these protocols were not followed. The lack of timely notification and intervention resulted in the resident not receiving appropriate treatment and monitoring for their diabetes.