Failure to Monitor and Treat Diabetes Leads to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and timely identify an acute change in a resident's condition, resulting in hospitalization for diabetic ketoacidosis (DKA) and sepsis. The resident, who had a history of type I diabetes with diabetic neuropathy and muscle weakness, was admitted with orders for scheduled and sliding scale insulin, as well as regular blood glucose monitoring. On multiple occasions, the resident's blood sugar was recorded as 'hi' (above the glucometer's readable range, typically >600 mg/dL), but there was inadequate monitoring and treatment. The resident did not receive scheduled insulin or blood sugar checks as ordered, and there was a significant lapse in monitoring between the evening and the following day. Documentation revealed that the resident experienced symptoms such as nausea, vomiting, and confusion, which were reported to staff but not adequately addressed. Staff interviews indicated that there was confusion and lack of communication regarding the resident's care, with missed medication administration and insufficient follow-up on abnormal blood sugar readings. Additionally, there was a lack of root cause analysis regarding a fall that occurred during this period, and the potential link between the fall and the resident's elevated blood sugar was not explored. Staffing shortages and unclear delegation of responsibilities contributed to the failure to provide necessary care and monitoring. The resident was eventually found unresponsive on the floor in her room, with critically high blood sugar, low blood pressure, and low oxygen saturation. She was transferred to the hospital, where she was diagnosed with DKA, sepsis, and other acute medical issues. The facility's failure to follow physician orders for insulin administration, monitor blood glucose as required, and respond to changes in the resident's condition resulted in actual harm and hospitalization.