Failure to Notify Physician and Administer Care for Critically Elevated Blood Glucose
Penalty
Summary
A deficiency occurred when nursing staff failed to follow physician orders and facility policy regarding the management of a resident with type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease. The resident was admitted with orders for blood glucose monitoring every six hours, with instructions to notify the physician if blood sugar exceeded 250 mg/dL. On the day in question, the resident's blood sugar was found to be 379 mg/dL, and later, upon transfer to the hospital, was recorded as greater than 500 mg/dL, with laboratory results showing a glucose level of 1,443 mg/dL. Despite these critical findings, the nursing staff did not notify the physician as required by the orders and facility policy. Interviews with the LVN and RN involved revealed that neither contacted the physician when the resident's blood sugar was elevated and the resident became unresponsive with hypotension. Instead, they called 911 and only notified the physician after the resident was already being transported to the hospital. The staff acknowledged that physician notification could have resulted in additional orders, such as insulin or fluids, but this step was omitted. The facility's policies on medication administration, diabetic care, and blood glucose monitoring all required physician notification for out-of-range blood glucose values, which was not followed in this case. Additionally, a review of the resident's medication administration record and feeding orders revealed that the resident missed 14 hours of prescribed tube feeding, which the Assistant Director of Nursing confirmed could contribute to unstable blood sugar and other complications. The failure to initiate the feeding as ordered and the lack of timely physician notification for both the elevated blood sugar and the resident's change in condition resulted in a delay in care and treatment for the resident, who was ultimately transferred to an acute care hospital with diagnoses including diabetic ketoacidosis and hyperkalemia.