Failure to Notify Physician After Resident Hypoglycemic Episode
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a diabetic resident’s hypoglycemic episode despite explicit orders and facility policies requiring such notification. The resident was admitted with diagnoses including type 1 diabetes, duodenal ulcer, and muscle weakness, and was documented as cognitively intact, requiring varying levels of assistance with activities of daily living. Active physician orders and the resident’s diabetes care plan both directed staff to call the provider immediately if the resident’s blood glucose was less than 70 mg/dL and to call as soon as possible when blood glucose values were regularly 70–100 mg/dL for possible regimen adjustment. On the day of the incident, progress notes documented that the resident’s pre-lunch blood glucose was 371 mg/dL and that insulin was administered as ordered. After lunch, the resident’s blood glucose was rechecked and found to be 60 mg/dL. In response, the nurse provided juice and a parfait, and a subsequent blood glucose check showed an increase to 72 mg/dL. The resident was monitored and noted to have no signs of distress. However, there was no documentation in the progress notes that the physician was notified of the hypoglycemic episode, despite the blood glucose level being below 70 mg/dL. During interviews, the LVN who provided care stated that she administered insulin per order, treated the low blood sugar with juice and a parfait, rechecked the blood sugar, and continued to monitor the resident, but forgot to notify the physician of the change in condition. Review of the electronic health record by the DON, QA nurse, and medical records director confirmed there was no documentation that the physician was notified of the hypoglycemic event. Facility policies on Management of Hypoglycemia and Change in a Resident’s Condition or Status required immediate provider notification for blood glucose less than 70 mg/dL and prompt physician notification of changes in a resident’s medical condition, particularly when there were specific instructions to notify the physician of such changes. The failure to notify the physician after the documented hypoglycemic episode constituted the cited deficiency.
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