Failure to Assess, Document, and Notify Physician of Hypoglycemia
Penalty
Summary
The facility failed to assess, document, and notify physicians of decreased capillary blood glucose (CBG) levels for three residents with diabetes. Facility policy required specific actions for hypoglycemia, including immediate notification of the provider, administration of glucose, monitoring, and documentation. However, clinical records and electronic medication administration records (eMAR) showed that when residents experienced low blood glucose readings, these protocols were not followed. For one resident with diagnoses including congestive heart failure and diabetes, multiple CBG readings below 70 mg/dL were recorded, but there was no evidence of assessment for hypoglycemia, monitoring for effectiveness of treatment, or physician notification as required by both physician orders and facility policy. The resident's care plan also lacked interventions for diabetes management, including hypo- or hyperglycemia. Another resident with diabetes had a CBG reading of 58 mg/dL, but again, there was no assessment, monitoring, or physician notification documented, despite care plan interventions instructing staff to report symptoms of hypo- and hyperglycemia. A third resident with diabetes had several CBG readings below 70 mg/dL, but the clinical record and eMAR did not show that the resident was assessed for hypoglycemia, that blood glucose was monitored for effectiveness of treatment, or that the physician was notified of abnormal results. The Director of Nursing confirmed that the facility failed to notify the doctor of a change in condition, failed to document assessments or interventions related to blood glucose, and failed to follow physician orders for these residents.