Failure to Assess Blood Glucose During Change in Condition
Penalty
Summary
Facility staff failed to assess a resident's blood glucose level during a significant change in condition, despite the presence of abnormal vital signs including low blood pressure, elevated heart rate, increased respiratory rate, low oxygen saturation, and a mild fever. The last recorded blood glucose measurement for the resident was from a week prior to the incident. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, with severely impaired cognitive functioning and a need for maximal assistance with daily activities. During the change in condition, the facility's policy required staff to gather all relevant and pertinent information, including blood glucose levels, before notifying a healthcare provider. However, the staff did not obtain a current blood glucose reading at the time of the event. This omission was acknowledged by the registered nurse, who stated that assessing blood glucose is necessary during such events to rule out related complications. The failure to follow professional standards and facility policy resulted in the resident not receiving appropriate assessment and care during a critical change in condition.