Failure to Follow Physician Orders for Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that physician orders for blood glucose monitoring and insulin administration were consistently followed for a resident with type 1 diabetes mellitus and a history of diabetic ketoacidosis. Despite multiple physician orders specifying the use of a Dexcom G7 sensor, scheduled blood glucose checks four times daily, and specific insulin administration parameters, the clinical record revealed repeated lapses. Blood glucose monitoring was not performed or documented as ordered, and the physician's order for scheduled checks was not transcribed onto the medication or treatment administration records for several months. There were also numerous instances where blood sugar readings were not recorded prior to insulin administration, and low or high blood sugar values were not consistently addressed or reported to the healthcare provider as required. The documentation showed that the resident frequently refused blood glucose checks and insulin administration, but there was no evidence that the physician was notified of these refusals or that the resident was monitored for signs and symptoms of hypo- or hyperglycemia following missed doses. On several occasions, the resident's blood sugar readings were outside of the ordered parameters, including both hypoglycemic and hyperglycemic episodes, yet there was no documentation of follow-up actions, rechecks, or provider notification. The care plan did not include specific interventions for blood sugar monitoring with either fingerstick or continuous glucose monitoring devices, and there was a lack of documentation regarding monitoring for symptoms or implementing change in condition protocols when abnormal readings occurred. Ultimately, the deficient practice resulted in the resident being admitted to the hospital's intensive care unit with hyperglycemia and diabetic ketoacidosis. The clinical record detailed that the resident was found with altered mental status, high blood sugar readings, and symptoms such as vomiting, tachypnea, and diaphoresis. Emergency services were called, and the resident was transferred to the hospital, where a diagnosis of diabetic ketoacidosis and acute encephalopathy was made. The failure to follow physician orders, monitor and document blood glucose levels, and notify the provider of abnormal findings directly contributed to the resident's acute medical deterioration.