Failure to Notify Provider and Representative of Critical Blood Sugar Levels
Penalty
Summary
Facility staff failed to notify the provider and resident representative (RR) of significant changes in condition for two residents with diabetes, as required by physician orders and facility policy. For one resident, multiple blood glucose readings exceeding 400 mg/dL were documented in the medication administration records (MARs) over several dates, but there was no evidence in the clinical record that either the provider or RR was notified of these critical results. The provider's order specifically instructed staff to call the medical doctor if blood sugar exceeded 400, yet this was not done. Interviews with nursing staff confirmed that it is standard practice and expectation to notify the provider and RR when blood sugar readings surpass dangerous thresholds, as indicated in the orders. Staff acknowledged that such instructions are routine and must be followed, emphasizing that 'an order is an order.' Despite this, review of the clinical records for both residents showed no documentation of required notifications following high blood sugar readings. The facility's policy on resident change in condition states that the licensed nurse must recognize and intervene in the event of a change, and notify the physician/provider and family/responsible party as soon as the change is identified and the resident is stable. However, in both cases, there was a lack of evidence that these notifications occurred, despite repeated instances of blood sugar levels exceeding the specified threshold.