Failure to Notify Physician of Elevated Blood Glucose per Order
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of an elevated blood sugar level as required by the physician’s order and facility policy. The resident was admitted with diagnoses including diabetes mellitus, hemiplegia, hemiparesis following cerebral infarction, and had moderately impaired cognition. The Minimum Data Set indicated the resident could make self-understood and understand others but was dependent on staff for multiple activities of daily living. A physician order dated 1/2/2026 directed staff to monitor blood sugar before meals and at bedtime and to notify the physician if blood sugar was less than 70 mg/dl or greater than 300 mg/dl. On 1/19/2026, the Weights and Vitals Summary and the Medication Administration Record documented that an LVN recorded the resident’s blood sugar as 335 mg/dl at approximately 9:00–9:30 p.m., which exceeded the threshold for required physician notification. During interviews and concurrent record reviews, the DON confirmed there was no documentation of any nursing intervention for monitoring hyperglycemia symptoms or of physician notification regarding the elevated blood sugar. The LVN acknowledged awareness of the order to notify the physician for blood sugars greater than 300 mg/dl and stated that they became busy and did not notify the physician when the 335 mg/dl result was obtained. The facility’s policy on “Change in a Resident’s Condition or Status” required prompt notification of the attending physician and documentation of changes in the resident’s condition, which was not followed in this instance.
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