F0580

D

Failure to Notify Physician of Repeated Critically High Blood Glucose Levels

Palm Harbor, Florida Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The facility failed to notify the physician of blood sugar levels (BSLs) that were outside the ordered parameters for one resident with type 2 diabetes mellitus with hyperglycemia and diabetic peripheral angiopathy on long-term insulin therapy. The resident had a Novolog sliding scale insulin order specifying insulin doses for BSLs from 150 to 450 mg/dL and explicitly directing staff to notify the physician if the blood sugar was less than 70 or greater than 400. Review of the Medication Administration Records (MARs) for November 2025 through January 2026 showed multiple BSL readings above 400, including specific values such as 420, 423, 409, 440, 450, 412, 408, 413, and 436 in January alone. In December, the resident had BSLs above 400 on 19 out of 120 tests, and in November, on 32 out of 120 tests.

Despite these repeated out-of-parameter BSLs, the resident’s medical record from November 2025 to January 2026 did not contain documentation that the physician was notified as required by the insulin order. During interview, the DON acknowledged that nurses should have documented notification of BSLs above 400 and stated that although the physician had increased the sliding scale to 450 because the resident’s baseline was higher, the instruction to notify the physician for BSLs greater than 400 had not been changed. The DON confirmed that, given how the current orders were written, there should have been documentation of physician notification when BSLs were above or below parameters. This practice was inconsistent with the facility’s “Notification of Change” policy, which requires prompt notification of the attending physician and resident representative when there is a need to alter treatment significantly or an exacerbation of a chronic condition, and requires documentation of such notifications in the medical record.