Failure to Notify Providers of Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians of significantly elevated capillary blood glucose (CBG) levels for two residents with diabetes, as well as the absence of clear provider notification parameters in policy, care plans, and physician orders. The facility’s policy on nursing care of older adults with diabetes, dated 8/27/25, stated that providers would order glucose monitoring frequency and establish glycemic targets, and that the facility would establish provider notification guidelines, but no specific facility protocol for notification was found. For one resident with dementia and diabetes, the care plan for potential hypo/hyperglycemia, revised on 9/26/24, did not include interventions related to physician notification for elevated blood sugars. A physician order dated 12/30/25 directed daily Basaglar insulin, but there were no orders for blood sugar checks or parameters for when to notify the physician. Review of this resident’s blood sugar records showed multiple markedly elevated CBG readings (ranging from 402.0 mg/dL to 524.0 mg/dL) on numerous dates and times without documentation that the provider was notified. For a second resident with epilepsy and diabetes, the care plan for potential hypo/hyperglycemia, initiated 10/19/23, referenced Accuchecks as ordered and to call the MD per order/facility protocol, but physician orders dated 12/30/25 only included Lantus insulin at bedtime and did not include blood sugar check orders or notification parameters. This resident’s blood sugar records also showed several elevated readings (ranging from 404.0 mg/dL to 482.0 mg/dL) without documentation of provider notification. During an interview, the Nursing Home Administrator and Director of Nursing confirmed the facility failed to notify physicians of increased and decreased CBG levels for two of five residents reviewed.
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