Failure to Monitor and Report Elevated Blood Glucose Levels per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a resident with type 2 DM, prior DKA, hemiplegia/hemiparesis following cerebral infarction, and aphasia. The resident was admitted in mid-January 2026 with orders for Empagliflozin (Jardiance) via PEG tube once daily and Insulin Glargine 8 units subcutaneously every 12 hours. An order dated 1/18/26 for PRN fingerstick blood glucose testing for hypo/hyperglycemia was present, but there were no blood glucose results documented on the January 2026 MAR. On 2/4/26, a new order was written for blood sugar monitoring every morning and at bedtime. Review of the Blood Sugar Summary showed that 9 of 14 recorded readings were above 200 mg/dL, including multiple readings over 400 mg/dL. Despite these elevated readings, there was only one documented physician notification on 2/2/26 when the blood sugar was 445 mg/dL, and no other evidence of physician notification when blood sugars were over 200 mg/dL or when they exceeded 400 mg/dL on consecutive days (2/4/26 and 2/5/26). An SBAR dated 2/6/26 documented a blood sugar of 405 mg/dL on the night of 2/5/26 and noted that the resident’s O2 saturation remained in the low 80s on 5 liters of oxygen, prompting transfer to the hospital. The hospital discharge summary for the stay from 2/7/26 to 2/18/26 indicated the resident was found to have blood glucose greater than 500 and was treated in the ICU with IV fluids and antibiotics. The DON stated that the resident’s blood sugar order was initially PRN, that an order for AM and HS monitoring was later obtained, and that her expectation was for licensed nurses to notify the physician when blood sugar was above 200 mg/dL. The facility’s diabetes clinical protocol, revised March 2025, indicated that residents receiving insulin who are well controlled should have blood glucose monitored twice daily and that staff should notify the practitioner when there are two or more readings higher than 250 mg/dL within 24 hours accompanied by a new medical problem or change in condition.
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