F0580

D

Failure to Notify Provider of Critically Elevated Blood Glucose Levels per Insulin Orders

Globe, Arizona Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders requiring provider notification for abnormal blood glucose levels for two residents with diabetes who were receiving insulin on sliding scale orders. For one resident with Type 2 Diabetes Mellitus, Stage 4 chronic kidney disease, long-term insulin use, a right heel pressure ulcer, and acute osteomyelitis of the right ankle and foot, a provider order dated October 20, 2025 directed staff to notify the provider and administer 12 units of Humalog for glucose levels of 351 mg/dL or greater. The resident’s diabetes care plan, initiated October 21, 2025, instructed staff to obtain blood sugar checks and administer medications as ordered, but did not include the specific sliding scale insulin parameters or the requirement to contact the provider when glucose exceeded 351 mg/dL. Review of the December 2025 MAR showed multiple blood glucose readings at or above 351 mg/dL on several dates, with no documentation that the provider was notified as ordered.

Further review of the same resident’s records showed that in January 2026 and February 2026, blood glucose levels again reached 351 mg/dL or greater on multiple dates, triggering the order to administer 12 units of Humalog and notify the provider. However, the clinical record contained no documentation that the provider was contacted for any of these elevated readings. The admission MDS indicated the resident was cognitively intact with a BIMS score of 15 and received daily insulin therapy. Interviews with facility staff, including a CNA, the RD, an LPN, and the DON, confirmed that staff understood that elevated blood glucose levels and sliding scale orders requiring provider notification must be reported to the provider, and the DON acknowledged that the provider should have been contacted for each instance and that no documentation of such notifications could be found.

For a second resident re-admitted with diagnoses including type 2 diabetes mellitus, long-term insulin use, and acute kidney failure, a physician order dated November 28, 2025, and again on December 5, 2025, specified Humalog insulin to be given subcutaneously before meals and at bedtime per a sliding scale, with instructions that for blood glucose levels of 351 mg/dL or greater, 10 units of insulin should be administered and the medical director called. Review of the December 2025 MAR showed multiple blood glucose readings above 351 mg/dL on several dates, and a February 2026 MAR entry showed a blood sugar of 449 mg/dL, with no evidence that the physician was notified on any of these occasions. Progress notes from December 2025 through January 2026 also lacked documentation of provider notification when blood sugars exceeded 351 mg/dL. Interviews with an LPN and the DON confirmed that the resident’s blood sugars were very high on the identified dates and that the provider was not notified, despite facility policy requiring orders to be followed and documentation to be consistent with professional standards and guidance indicating that persistent elevated readings above the ordered sliding scale should be communicated to the provider.