Failure to Notify Provider and Assess After Critically High Blood Sugar Readings
Penalty
Summary
Facility staff failed to carry out required assessments and interventions after a resident experienced multiple episodes of significantly elevated blood sugar levels. The resident, who had diagnoses including diabetes, heart failure, and coronary artery disease, had care plan directives and physician orders specifying that staff should notify the provider if blood sugar readings exceeded 500 mg/dl. Despite this, clinical records showed that on several occasions, the resident's blood sugar readings were well above this threshold. Documentation revealed blood sugar readings of 547 mg/dl and 600 mg/dl on one day, and 538 mg/dl on another, without any evidence that the provider was notified or that follow-up assessments or monitoring were conducted. The facility's policy required staff to follow physician-ordered parameters for reporting high blood sugars, but there was no documentation to show these protocols were followed. Interviews with the DON confirmed that no additional documentation or provider notification could be found regarding these incidents.