Failure to Notify Providers of Significant Changes and Abnormal Clinical Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify providers of significant changes in condition and abnormal clinical findings for two residents. One resident with type 1 diabetes mellitus and an order to obtain blood sugars before meals and at bedtime, with instructions to notify the physician for blood glucose levels less than 60 or greater than 200, had multiple documented blood sugar readings far above the ordered threshold. These included values in the 400–551 range on numerous dates. Review of the electronic medical record showed no documentation that the provider was notified of any of these elevated blood sugar results. When surveyors requested evidence of provider notification, the Nursing Home Administrator acknowledged there was no documentation, and the DON stated that the expectation was for licensed nurses to notify the provider of elevated blood sugars, typically when readings were greater than 450. The second resident, who had heart disease and a cardiac pacemaker, experienced an episode of left-sided chest pain for which nitroglycerin was administered. Vital signs at that time included a blood pressure of 158/90, pulse 73, respirations 18, temperature 97.3, and oxygen saturation of 93% on room air. Nursing documentation indicated that the nurse notified the resident’s wife of the condition and that she advised continued monitoring and possible hospital transfer if the condition worsened. However, there was no documentation in the electronic medical record or provider communication log that the provider was notified of this chest pain episode, despite the resident’s complex cardiac history. The DON confirmed there was no documentation of provider notification. The report cites a nursing textbook outlining failure to communicate abnormal assessment data or significant changes in status as a common negligent act.
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