Failure to Promptly Intervene and Escalate Care for Severe Hypoglycemia
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including type II diabetes mellitus, experienced a severe hypoglycemic episode that was not managed according to professional standards of practice and facility policy. The resident was first found to have a critically low blood glucose level of 42 mg/dl in the early morning by a night shift LPN, who administered glucagon but did not promptly notify the nurse practitioner or physician as required. Despite repeated low blood glucose readings and additional doses of glucagon and oral carbohydrates, the resident's condition did not improve, and there was a prolonged period—over two hours—where the resident remained hypoglycemic and increasingly unresponsive. The nursing staff failed to escalate care in a timely manner. The night shift LPN endorsed the situation to the incoming day shift LPN without notifying the medical provider, and both nurses continued to monitor and treat the resident without achieving a safe blood glucose level or seeking immediate higher-level intervention. Documentation and interviews confirm that the nurse practitioner was not notified until the resident developed respiratory distress and further decline in condition. Only at this point was 911 called and the resident transferred to the hospital. Throughout this episode, facility policy and standard hypoglycemia protocols were not followed, specifically regarding prompt provider notification and emergency escalation for persistent severe hypoglycemia. The lack of timely intervention and failure to follow established protocols resulted in the resident experiencing prolonged hypoglycemia, decreased responsiveness, and ultimately requiring emergent hospital transfer, where the resident expired the same day.
Removal Plan
- Juice was provided to the resident to improve the blood glucose level.
- Glucagon was administered.
- Blood glucose monitoring was performed.
- Nurse Practitioner was notified and resident transferred to ER via 911.
- R1 no longer resides in the facility.
- 1:1 education was provided to the day shift nurse and night shift supervisor regarding hypoglycemia protocol, change of condition policy, following physician orders, and emergency response associated with severe hypoglycemia.
- The night shift nurse is no longer employed by the facility.
- DON/designee conducted a whole-house audit of residents who require blood glucose monitoring to ensure blood glucose results are within the ordered parameters, and if physician / NP is notified if the results are outside the parameters.
- Residents who are at risk for hypoglycemia (residents with diagnosis of diabetes, receiving insulin) were reviewed to ensure the plan of care includes a physician order for parameters of blood glucose level to monitor signs and symptoms of hypoglycemia, administer interventions for treatment of hypoglycemia, and physician notification.
- Staff education was conducted by the DON, Regional Nurse Consultant and shift supervisor. Education included: Notification of a change in condition, Medical emergency procedure associated with hypoglycemia, Following the physician's orders, Hypoglycemia Protocol.
- All licensed nurses received education prior to working their next scheduled shift. Staff not on site for education were contacted by telephone and received verbal education. They will sign in-service education forms at the time of their next shift. This includes PRN staff.
- Understanding of the in-service content was evaluated at the time of in-service through questions and answers.
- Director of Nursing or designee will audit resident records to ensure prompt notification to physician/ NP of an episode of hypoglycemia (change in condition) and following the physician's orders for notification of blood sugars outside of established parameters.
- Director of Nursing or designee will review the clinical record to monitor staff response to residents with signs and symptoms of hypoglycemia, monitor residents experiencing hypoglycemia, including severe hypoglycemia, administer interventions for treatment of hypoglycemia, and when emergency transport (911) and the medical provider are notified.
- Audits will be conducted 5 times a week for all residents with blood glucose monitoring orders.
- Audits will be conducted weekly for a sample of 10% of residents with blood glucose monitoring.
- Results of the audits will be presented to the QAPI committee for recommendations of further auditing and actions as appropriate.
- Root cause analysis is completed, and the action plan is discussed and approved by the Ad-Hoc committee.