Failure to Notify Provider of Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify the attending physician of elevated blood glucose levels as required by a physician’s order and the resident’s diabetic care plan. A resident with multiple diagnoses, including diabetes, severe protein-calorie malnutrition, and a need for assistance with personal care, had a diabetic care plan revised on 1/22/26 that directed staff to provide timely notification to the physician for any change in condition. A physician’s order dated 2/2/26 specified administration of Insulin Aspart per sliding scale and required staff to give 6 units and notify the provider when blood glucose was greater than 351. Review of the MAR from 2/2/26 to 3/18/26 showed multiple blood glucose readings above 351 (384, 378, 366, 365, 362, 506, and 409), all meeting the threshold for provider notification. When surveyors requested documentation of provider notification for these elevated readings, the DON confirmed she was unable to locate any documentation that the provider had been notified. This failure to follow the physician’s order and the care plan regarding provider notification for elevated blood glucose levels constituted the cited deficiency.
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