Failure to Monitor and Communicate Blood Glucose Management in Diabetic Resident
Penalty
Summary
A deficiency occurred when facility staff failed to follow professional standards of practice and the facility's policy for managing, assessing, and monitoring a resident with diabetes mellitus. The resident, who had a history of type II diabetes, end stage renal disease, and congestive heart failure, was found to have a blood sugar level of 348 mg/dl in the morning. Despite this elevated blood sugar, the nurse on duty administered insulin but did not recheck the resident's blood sugar, notify the physician, or communicate the high blood sugar to the oncoming nurse during shift hand-off. There was also a lack of documentation regarding the interventions taken in response to the high blood sugar reading. Later that day, the resident was found unresponsive, lethargic, and difficult to arouse, with labored breathing and high blood pressure. Upon assessment, the oncoming nurse found the resident's blood sugar had dropped to 70 mg/dl, indicating hypoglycemia. However, this critical blood sugar reading was not documented, and the nurse acknowledged that it should have been. The facility's policy required immediate provider notification for hypoglycemia and prompt notification for blood glucose values over 250 mg/dl, as well as documentation of interventions and changes in the resident's condition, none of which were followed in this case. Interviews with nursing staff and the Director of Nursing confirmed that the required monitoring, documentation, and communication protocols were not adhered to. The staff failed to recheck blood sugar after insulin administration, did not notify the physician or the next shift about the resident's condition, and did not document key interventions or changes in the resident's status, all of which contributed to the deficient practice.