F0684

G

Failure to Monitor and Manage Blood Glucose and IV Dextrose Therapy for Diabetic Resident

Glendale, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and services in accordance with professional standards of practice for a resident with Type 2 DM following readmission from a GACH. The resident’s GACH discharge recap dated 1/11/2026 included orders to renew fingerstick blood sugar monitoring AC and HS, with parameters to notify the physician for BG >250 mg/dL or <70 mg/dL and to implement a hypoglycemia protocol. Upon readmission, the facility’s admission record reflected diagnoses of Type 2 DM and sepsis, and nursing notes documented that the attending physician’s orders were “verified and carried out.” However, the physician order report from 1/11/2026–1/31/2026 did not include any orders for AC/HS fingerstick BG monitoring or monitoring for signs and symptoms of hyperglycemia, only an order to monitor for signs and symptoms of hypoglycemia three times daily. The nurse who spoke with the physician at readmission did not document that the physician declined to reorder fingerstick monitoring or the rationale, and there was no documentation in the physician or NP progress notes explaining why BG monitoring was not continued despite the diagnosis of Type 2 DM and the GACH discharge instructions.

The resident’s existing care plan, titled “Risk for Unstable Blood Glucose Level,” required staff to observe for signs and symptoms of low and high BG and to check BG if it was below 70 mg/dL, with instructions to administer IM glucagon and call 911 if the resident was unconscious or without vital signs. However, the care plan did not specify how licensed nurses would measure BG levels (e.g., via fingerstick) to determine whether levels were low or high. Facility policies on blood glucose monitoring for diabetic residents experiencing a change of condition and on diabetic management required BG monitoring for residents with DM, particularly when they had changes in condition, infections, poor oral intake, or were receiving dextrose-containing IV fluids, and indicated that failure to monitor BG in such situations may place residents at risk for hyperglycemia, hypoglycemia, dehydration, and hospitalization. Despite these policies and the resident’s diagnosis of Type 2 DM, staff and the NP acknowledged that the resident was not being monitored with fingerstick BG checks and that DM management relied on oral hypoglycemic medications and periodic blood work.

On 2/5/2026, a stat CMP showed a fasting BG of 351 mg/dL. Nursing documentation indicated that this abnormal lab result was communicated to the attending physician via text and voicemail, and the lab results were faxed, but the nurse did not document which value was abnormal. Another nurse later texted a screenshot of the stat lab results, including the elevated BG, to the physician. The physician did not issue new orders to address the hyperglycemia but instead ordered a 1 L NS bolus via IV (from the NP) and then, on 2/6/2026, ordered D5W IV at 60 cc/hr for a total of 3 L due to poor appetite. Nursing staff started and continued the D5W infusion without reviewing or acting on the elevated BG of 351 mg/dL, without clarifying the appropriateness of D5W in the setting of hyperglycemia, and without initiating or obtaining orders for BG monitoring. Multiple RNs later acknowledged they had not reviewed the stat lab results before starting or continuing D5W, did not clarify DM monitoring parameters with the physician, and did not monitor for signs and symptoms of hyperglycemia while the D5W was infusing.

On 2/8/2026, the resident experienced a change in condition characterized by non-responsiveness, shallow respirations, tachypnea, tachycardia, fever, oxygen saturation in the 80s, and a BG of 463 mg/dL documented by facility staff. An SBAR reflected these findings and the administration of oxygen via non-rebreather at 15 L, with improved oxygen saturation. EMS was called, and paramedics found the resident with altered level of consciousness, tachycardia, labored respirations, fever, and an IV of D5W still infusing at 60 cc/hr. Paramedics reviewed prior lab results showing a fasting BG of 351 mg/dL from 2/5/2026, requested that nursing staff check a current BG (which was 530 mg/dL), and instructed the nurse to discontinue the D5W, which they observed being stopped at that time. EMS documentation and ED records indicated that the resident had been receiving D5W despite hyperglycemia, with ED notes stating that the facility had treated a BG of 350 mg/dL with dextrose. The resident was transferred to the GACH ED, where BG readings remained critically elevated, and diagnoses included uncontrolled DM and severe hyperglycemia. The facility’s DON and medical director later stated that the D5W infusion in the presence of hyperglycemia would further elevate BG and that residents with Type 1 or 2 DM should be monitored with fingerstick BG AC and HS, and the DON acknowledged that the lack of BG monitoring and failure to clarify orders contributed to the resident’s elevated glucose levels and subsequent transfer.

Throughout this period, there was ineffective communication among nursing staff, the physician, and the NP regarding the resident’s change in condition, critical lab results, and ordered treatments. Nurses reported that abnormal lab results were not clearly endorsed between shifts, that they did not review the stat lab results before implementing IV fluid orders, and that they did not inform the NP about the elevated BG or the change from NS to D5W. The NP stated she was unaware of the elevated BG of 351 mg/dL, unaware that D5W was being infused instead of NS, and would not have ordered D5W in a hyperglycemic state. The attending physician stated he intentionally did not reorder fingerstick BG monitoring at readmission and ordered D5W despite knowing the resident was hyperglycemic, but did not document this plan in the record. The combination of not implementing or clarifying BG monitoring orders, not operationalizing the care plan to include specific BG measurement methods, not acting on critical lab results, and continuing D5W infusion in the presence of hyperglycemia led to the resident not receiving required monitoring and timely intervention for hyperglycemia.