F0711

D

Failure to Act on Abnormal Blood Glucose Labs for Diabetic Resident

Fremont, California Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

Facility staff notified the attending physician on two occasions about a resident’s elevated blood glucose levels but the physician did not review the laboratory results, discuss the resident’s status with nursing staff, or change the treatment regimen. The resident, who had severe cognitive impairment with a BIMS score of 6/15 and a diagnosis of type 2 diabetes, had an admission record and MDS documenting these conditions. The DON stated that lab results were filed in the EHR after being received and reviewed by nurses, that physicians had access to the EHR, and that nurses were responsible for placing lab results in the paper chart and documenting physician notification with date, time, and signature on the lab results after communication.

The physician reported relying on nursing staff to communicate abnormal lab results by phone or text and stated that abnormal results warranted additional orders. 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 physician described as very high and warranting additional orders, but this report was not sent or reviewed by the physician. A CMP dated 2/21/2025 showed a glucose level of 273 mg/dL, which the physician also stated was high and required notification for additional orders. The physician indicated that all orders and new orders were based on communication from nurses during resident assessments and emphasized the importance of abnormal lab results being communicated for proper interventions.

Record review showed that the physician did not sign the 3/16/2024 lab results to indicate review or initiate new orders, despite facility text message records showing that the physician was notified of the lab results with three photos and did not respond. Similarly, the CMP from 2/21/2025 had a notation that the physician was notified by an LVN, but the physician did not sign the lab results or initiate new orders. Subsequently, the resident was admitted to a general acute care hospital with altered mental status, including lethargy, confusion, partial responsiveness, and weakness, and hospital labs documented a blood glucose greater than 800 mg/dL. Facility policies on physician notification and lab/diagnostic test results required timely physician response and documentation of when, how, and to whom information was provided, as well as the physician’s response, but the physician did not document review or respond with new orders for the abnormal lab results.