Failure to Notify Provider of Critically High Blood Sugar Levels per Insulin Orders
Penalty
Summary
Facility staff failed to follow provider orders for the administration of insulin for two residents. For one resident, provider orders specified that if blood sugar exceeded 400, the provider should be notified. Clinical record review showed multiple instances where the resident's blood sugar was above 400, but there was no evidence that the provider was notified as required. Medication administration records documented blood sugar readings above the threshold on several dates, yet the clinical record lacked documentation of provider notification. Interviews with nursing staff confirmed that the standard practice is to notify the provider when blood sugar readings exceed specified parameters in sliding scale insulin orders. Staff acknowledged that an order is to be followed as written, and that both the provider and resident representative should be notified when such parameters are exceeded. However, review of the records indicated that this protocol was not followed for the residents in question. Administrative and nursing leadership were made aware of these concerns during the survey. The facility's policy on provider orders did not include information regarding the nursing staff's responsibility to follow such orders. No additional information or documentation was provided to demonstrate that the provider was notified in the identified cases.