Failure to Monitor and Respond to Hypoglycemia in Diabetic Resident
Penalty
Summary
A facility failed to provide treatment and care in accordance with professional standards of practice, the resident's care plan, and the resident's choices for a resident with multiple comorbidities, including end-stage renal disease, hypertension, and diabetes mellitus. The resident was found lethargic with a critically low blood sugar reading that did not register on the monitor, and after administration of glucagon, her blood sugar was recorded at 25 mg/dL. EMS was called, but the resident was not transported to the hospital at that time, and the physician was not notified of the change in condition. There was no documentation of ongoing monitoring or follow-up by nursing staff after this event. For approximately 13 hours following the initial hypoglycemic episode, the resident's blood sugar was not monitored, and there were no further nursing assessments or documentation regarding her condition. The resident was later found unresponsive with a blood sugar of 21 mg/dL, and EMS was called again. This time, the resident was transported to the hospital, where she was admitted with altered mental status and hypoglycemia, and subsequently required ICU care due to worsening hypotension. Interviews with staff revealed that the physician was not notified of the resident's critical condition, and there was a lack of adherence to the facility's hypoglycemia protocol, which required frequent blood sugar monitoring and physician notification for low blood glucose levels. The facility's change of condition policy, which mandates physician notification and documentation using the SBAR tool, was not followed. The failure to monitor the resident's blood sugar, notify the physician, and document the resident's status after a critical event led to a second hypoglycemic episode and the need for emergency medical intervention.