Failure to Notify Physician of Abnormal Blood Glucose Readings
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of abnormal blood glucose readings as ordered for a resident with type 2 diabetes mellitus, hypertension, and dementia. The resident’s care plan, dated 4/2/25, identified risk for complications and symptoms of hypoglycemia and hyperglycemia and included an intervention to obtain blood sugars as ordered and to document and notify the physician of abnormal findings. A physician’s order, dated 4/3/25 and discontinued 4/2/26, directed staff to obtain Accu-Chek blood sugar readings four times daily and to notify the provider if the blood sugar was less than 90 or greater than 350. Review of the Medication Administration Record showed multiple abnormal blood sugar readings during the ordered period that were marked with “N” for no physician notification, including low readings of 85, 74, 80, 83, 82, and 84, and high readings of 368 and 367. Interviews revealed that when “N” was documented on the MAR, the physician would not have been notified, and the Executive Director was unable to find documentation of physician notification for the low blood sugar readings. The Executive Director also stated that if the physician had been in the building at the time of an abnormal reading, the nurse would have notified the physician and documented it in a progress note, but no such documentation was found. Additionally, the Executive Director reported that the facility did not have a policy regarding call orders and physician notification.
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