Failure to Assess and Report Critically Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to assess and notify the physician regarding a resident’s persistently elevated blood glucose levels as ordered and expected. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, post-hemorrhagic stroke, congestive heart failure, depression, and anemia, and had intact cognition with a BIMS score of 15. Physician orders included accu checks before meals and at bedtime starting on 01/03/26. Blood glucose readings over several days showed repeated and significant elevations, including values of 403 mg/dl on the evening of 01/10/26; 195, 236, 326, and 376 mg/dl on 01/11/26; 353, 399, 277, and 373 mg/dl on 01/12/26; and 443 and 493 mg/dl on the morning and late morning of 01/13/26. Despite these elevated readings, the medical record contained no evidence of further assessment of the resident related to the high blood sugars and no documentation that the physician was notified. The DON confirmed there were no parameters on the accu check order specifying when to notify the physician, verified that no additional assessment was completed, and that the physician was not notified before the resident was discharged home with home health. The attending physician stated she had not been informed of the elevated blood glucose levels and that she would have expected notification for blood glucose levels greater than 350 mg/dl. Information from the American Diabetes Association cited in the report defined hyperglycemia as blood sugar levels above 240 mg/dl and noted that untreated hyperglycemia could lead to serious complications, including ketoacidosis.
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