F0711

G

Failure to Review Critical Glucose Result Before Ordering Dextrose-Containing IV Fluids

Farmington Hills, Michigan Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the failure of the attending provider to review and act upon critical laboratory results before ordering and continuing IV fluids containing dextrose. A resident with psychotic disorder with delusions, delirium, Alzheimer's disease, stroke, and mood disorder was noted by a CNA as "wasn't herself" on the morning of 12/8/25. Nurse B contacted the on-call PA, who ordered STAT labs including a CBC and CMP. Labs drawn that morning and reported at 12:37 PM showed a critically high blood glucose level of 732 (normal 70–99). Nurse B later documented at 3:24 PM that they reviewed the lab results with the PA while the PA was in the building, and that new orders were received for D5% 0.45% NS at 125 ml/hr for 3 liters, with an IV started but then pulled out by the resident.

The PA’s progress note for 12/8/25 documented an assessment of acute kidney injury and a plan to give 2 liters of IV fluid continuous, but did not document review of the STAT labs or specify the type of IV fluid. Subsequent nursing notes show that on the afternoon of 12/8/25 the PA called back with new orders for hypodermoclysis, which was initiated. On 12/9/25, Nurse G documented placement of a new PIV and that the resident was hooked up to IV fluids as ordered, specifically D5% 0.45% NS per the PA’s prior order. Nurse H documented an order clarification for D5% 0.45% NS infusing at 125 cc/hr times 2 liters, and Nurse I documented that the resident had a peripheral IV in the right forearm with D5% 0.45% NS infusing at 125 cc, bag 2 of 2.

In the early hours of 12/10/25, Nurse C documented that the resident was resting in bed with D5% 0.45% NS infusing via right arm PIV, and that the resident was hard to arouse. A blood sugar check at that time read "Hi" on the glucometer, and the on-call NP was contacted. New orders were received to give 12 units of Lispro insulin, recheck in 2 hours, and repeat 12 units if the blood sugar still read "Hi," with instructions to call back if it remained "Hi" after the second dose. Subsequent notes by Nurse C documented repeated "Hi" blood sugar readings, administration of Lispro insulin, the resident being lethargic and difficult to arouse, and that an ambulance was called for transfer to the hospital. Hospital records indicated the chief complaint was high blood sugar and altered mental status, and EMS reported the patient was receiving D5 fluid hydration on their arrival. In an interview, the PA stated they were not aware of the glucose level of 732 prior to ordering D5% 0.45% NS, acknowledged they did not document lab review, and stated they would not have ordered IV fluid with dextrose if they had known. The DON indicated that the PA’s order for D5% 0.45% NS could have been questioned by the nurse who received the critical glucose result and implemented the order. The facility’s policy requires providers to review laboratory tests during visits and analyze abnormal results with documented rationale and interventions.