Failure to Notify Provider of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to notify the provider when a resident's blood glucose levels exceeded 400 mg/dl, as required by physician orders and facility policy. The resident in question had a diagnosis of Type II diabetes mellitus, was severely cognitively impaired, and was receiving insulin therapy. The care plan and physician orders specifically directed staff to call the medical provider for blood glucose readings above 400 mg/dl. Despite this, multiple blood glucose readings over 400 mg/dl were documented in the electronic medical record without corresponding documentation that the provider was notified. Staff interviews confirmed that it was standard practice to notify the provider for such readings, but one LPN stated she did not recall ever calling for this resident's high blood sugars. The DON acknowledged the lack of documentation and suggested that nurses may have called but failed to chart it. The resident's medical record showed several instances where blood glucose levels were significantly elevated, including readings as high as 584 mg/dl, without evidence of provider notification. Nursing notes indicated attempts to administer insulin were refused by the resident, and while there was some communication with a doctor regarding symptoms and monitoring, there was no documentation of provider notification for all high readings as required. The facility's policy required nurses to notify the physician of changes in the resident's condition, including specific instructions for blood glucose thresholds, but this was not consistently followed or documented.