F0580

E

Failure to Notify Providers of Critically Elevated Blood Glucose Levels

Monroeville, Pennsylvania Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify physicians of significantly elevated capillary blood glucose (CBG) levels for four residents with diabetes, contrary to facility policy and physician expectations. The facility’s Diabetes – Clinical Protocol stated that physicians would order appropriate interventions for diabetes management. The Centers for Disease Control definition of hyperglycemia was cited, and the facility’s care plans for several residents directed staff to monitor, document, and report signs and symptoms of hyperglycemia as needed. Despite these directives, multiple documented CBG readings far above normal ranges were not followed by documented provider notification.

One resident with heart failure and diabetes had a care plan to monitor and report signs and symptoms of hyperglycemia and a physician order for Humalog insulin per sliding scale, with instructions to call the physician if blood sugar exceeded 500 mg/dL. The resident’s blood sugar record showed numerous readings at or above 500 mg/dL, including values such as 547, 589, 525, 594, 571, 561, 509, and 570 mg/dL, without documentation that the physician was notified. Another resident with dementia and diabetes had a care plan to monitor and report hyperglycemia and an order for scheduled Humalog insulin three times daily, but no specific notification parameters. This resident’s blood sugar record showed multiple elevated readings, including 410, 404, 539, 412, and 400 mg/dL, again without documentation of provider notification.

A third resident with end stage renal disease and diabetes had an order for Humalog insulin per sliding scale with instructions to call the physician if blood sugar exceeded 400 mg/dL. The blood sugar record showed a reading of 489 mg/dL without documentation that the physician was notified. A fourth resident with coronary artery disease and diabetes had a care plan to monitor and report signs and symptoms of hyperglycemia and an order for scheduled Humalog insulin three times daily, but no specific notification parameters. This resident’s blood sugar record contained numerous elevated readings above 400 mg/dL, including values such as 412, 441, 423, 464, 481, 533, 457, 428, 445, 460, 500, 488, and others, with no documentation of provider notification. In interviews, the Medical Director stated that staff were expected to notify providers of out-of-range blood sugars and, in the absence of specific parameters, to notify at levels of 400–450 mg/dL unless otherwise specified. The Nursing Home Administrator and Director of Nursing confirmed that the facility failed to notify physicians of increased CBG levels for four of six reviewed residents.