F0580

J

Failure to Notify Physician of Low Blood Glucose in Insulin-Dependent Resident

Edmond, Oklahoma Survey Completed on 02-27-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to notify a physician of a resident’s low blood sugar as required by existing medical orders and facility policy. Resident #129 had an admission MDS dated 11/24/24 showing a BIMS score of 10, indicating moderate cognitive impairment, and that they received insulin injections. The resident’s baseline assessment and care plan documented a diagnosis of type 2 diabetes mellitus with hyperglycemia. A physician’s order dated 11/18/24 directed staff to use a Glucagon Emergency Injection Kit as needed for finger-stick blood sugar (FSBS) less than 71, to give cola/orange juice and/or a high carbohydrate snack, and to notify the physician when FSBS was below 71.

On 11/27/24 at 8:00 p.m., documentation on the Injections/Insulin/FSBS record for Resident #129 showed a blood sugar of 64. Despite this result being below the ordered threshold of 71, the physician was not notified as required by the physician’s order. The same record showed that the resident was administered 40 units of long-acting insulin (Toujeo SoloStar subcutaneous solution). RN #1 later confirmed that their initials on the November 2024 Injection/Insulin/FSBS administration record indicated the blood sugar was 64 and acknowledged they did not call the physician per the existing orders.

On 11/28/24 at 9:07 a.m., a nurse’s progress note documented that Resident #129 was assessed as unresponsive and not reacting even to a sternal rub. Vital signs were recorded as 130/73, 78, 96%, 12, and 97.8. The nurse called 911, and emergency medical services arrived and reported the resident’s FSBS was 41 before transporting the resident to the hospital. Interviews with nursing staff and the DON confirmed that the expectation, consistent with facility policy and the medical director’s statement, was that nurses notify the physician when a resident’s blood sugar is below 71, and that this did not occur for Resident #129 on the evening the FSBS of 64 was recorded.

Removal Plan

• In-service all licensed nursing staff on signs and symptoms of hypoglycemia and when to notify physician.
• Audit all residents with hypoglycemia parameters ensuring notification order is in place.
• Add monitoring orders for appropriate residents for signs and symptoms of hypoglycemia with notification order attached.
• Place parameter and notification orders for all residents with hypoglycemia below 70 and notify.
• Conduct root cause analysis.
• Review all residents with hypoglycemia and/or diabetes to ensure parameters are in place to notify physician.