IDPH has cited and fined Alden Estates of Orland Park nursing home after the failure of the nursing staff to provide insulin to a diabetic resident resulted in the admission of the resident to the hospital with critically high blood sugar levels.
The resident at issue was a new admission to the nursing home who had orders in place for a long-acting insulin dose at bedtime, plus an additional order for sliding scale insulin where if the resident’s blood sugar testing showed elevated blood sugar levels, then the resident would be given units of insulin to reduce her blood sugar levels.
When the resident was initially admitted to the nursing home, she was given a room on the second floor, but was transferred within a matter of hours to a room on the first floor. When the transfer occurred, the nurse receiving the patient did not get a report on the resident from the prior nurse. With her shift coming to an end, she instructed the nurse coming on duty to get a report from the nurses on the second floor.
Communication is one of the keys to delivering quality care in a nursing home setting. “Report” among nurses is a conversation among the nurses where they discuss the residents who are coming under their care. It is one of the keys to ensuring continuity of care. Nursing homes operate in part on the basis of communications systems such as the resident chart, 24-hour sheets, and care plans. When members of the nursing home staff fail to communicate, errors are made in caring for the resident which can be seen in blog posts here, here, and here.
In this case, the failure to communicate resulted in this resident not receiving her dose of long-acting glucose at bed time, not having her blood sugar testing done, and not receiving whatever additional insulin which would have been required based on the results of the testing. As a result, she was transferred to the hospital the next morning with an elevated blood sugar level (kyperglycemia) of 525, when the normal range is 70-99. This kind of medication error can have serious consequences for a diabetic resident, including diabetic ketoacidosis, diabetic coma, or even cause the wrongful death of the nursing home resident.
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