F0580

E

Failure to Notify Physician of Elevated Blood Glucose per Insulin Order

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The facility failed to notify a physician when a resident’s finger-stick blood sugar (FSBS) exceeded 350 mg/dL, as required by the resident’s insulin order and the facility’s physician notification policy. The policy stated that licensed nurses are responsible for notifying medical staff of significant changes in condition and documenting the date, time, physician name, actions taken, and resident response. A physician’s order dated 12/31/25 for Humalog insulin directed staff to administer 10 units subcutaneously before meals for FSBS levels of 350–400 mg/dL and to notify the medical doctor. Record review for February showed multiple FSBS readings above 350 mg/dL for this resident, with corresponding administration of 10 units of Humalog insulin on several dates and times.

Despite these elevated FSBS readings and the explicit order to notify the physician when FSBS was between 350 and 400, there was no documentation in the progress notes or medication administration record that the provider had been notified. The resident, who had a diagnosis of diabetes and intact cognition with a BIMS score of 14, reported that their blood sugar had been well controlled (around 100–200) prior to admission and that it had reached as high as 370 in the facility. During interviews, an RN confirmed that the process for insulin administration included obtaining and documenting FSBS and that physician notifications should be documented in progress notes. The RN acknowledged that the resident’s order required physician notification for FSBS of 350–400, could not locate any such documentation, and stated that the provider had not been notified for an FSBS of 375. The DON also stated that staff should notify the physician if the order stated to do so.