Failure to Monitor and Follow Up Abnormal Glucose Labs for Diabetic Resident
Penalty
Summary
The deficiency involves the failure of the attending physician to provide appropriate laboratory orders and follow-up for a resident with type 2 diabetes who was receiving oral sitagliptin. The resident, who had severe cognitive impairment (BIMS score 6/15), malnutrition, and type 2 diabetes, was admitted in March 2024 with an order for sitagliptin. A lab report dated 3/16/2024 showed a hemoglobin A1C of 10.8% and an estimated average glucose of 263 mg/dL, which the DON and MD both described as elevated and very high, warranting additional orders. The lab results were reviewed in the EHR by the ADON, and the facility’s process was that abnormal labs should be communicated to the MD via fax, phone, or text. However, the MD stated that the 3/16/2024 lab report was not reviewed by him and that he relied on nursing staff to notify him of abnormal results, and he did not follow up on ordered lab results independently. A subsequent Comprehensive Metabolic Panel collected on 2/21/2025 showed a glucose level of 273 mg/dL, which the MD also stated was high and warranted MD notification for additional orders. Medical Records and the Administrator reported that although the MD had access to the facility’s EHR, he used a personal EHR system, and MR uploaded SOAP notes, history and physicals, lab results, past medical history, and current medications into that system monthly per the MD’s request. The facility’s diabetes clinical protocol required the provider to order desired glucose targets and monitoring regimes and to assess glycemic status by A1C and blood glucose monitoring, and the lab/diagnostic testing policy required the physician to identify and order diagnostic and lab testing based on residents’ needs. Despite these policies and the abnormal lab findings, there were no documented additional lab orders for routine monitoring, and the resident was later admitted to a general acute care hospital with altered mental status, lethargy, confusion, partial responsiveness, and weakness, where a lab result showed blood glucose greater than 800 mg/dL.
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