IDPH has cited and fined Champaign Urbana Nursing & Rehabilitation located in Savoy after the nursing staff failed to notify the doctor of abnormal lab results leading to the hospitalization of the resident for hyperosmolar hyperglycemia coma due to diabetes mellitus.
This long-term resident was a diabetic but had never been on diabetes medications while a resident at the facility. In September, 2017, her doctor ordered a set of labs on her since there were no lab results in the chart for her since 2016. Between September 7, 2017 and October 30, 2017, the following lab tests were done with the following results:
- 9/9/17 – glucose level was 120 (H) (normal fasting level is 65-99)
- 1/29/18 – glucose level was 168 (H) (normal fasting level is 65-99)
- 5/25/18 – glucose level was 200(H) (normal fasting level is 65-99)
- 10/3/18 – glucose level was 240 (H) (normal fasting level is 65-99)
- 10/30/18 – glucose level was 794 (critically high); hemoglobin A1C 14.2% (critically high)(normal is 4.1 – 6.1%)
On October 30, 2018, the resident’s grandaughter came to the facility and saw that her grandmother was having difficulty talking and was not her usual self. She was seen by an Advance Practice Nurse who obtained the labs that day and ordered her sent to the hospital. On arrival at the hospital her glucose level was 909 and other labs were showing signs of dehydration. She was admitted to the hospital with a diagnosis of Hyperosmolar Hyperglycemia Coma due to Diabetes Mellitus.
There were no lab reports in the resident’s chart, and when the state surveyor arrived, they had to be obtained from the laboratory. One of the basic tasks of nurses in a nursing home setting is to serve as the eyes and ears of the doctor. When a doctor orders lab work to be performed, it is the role of the nursing staff to see that it is done and that the results are forwarded to the doctor. Nurses are also responsible for notifying a doctor about abnormal labs results, as all of these were.
This has not been done in this case, and the attending doctor was clear about the consequences of this: that the resident’s diabetes went untreated for over a year. Had he been notified of the abnormal labs in September, 2017, she would have been started on medications to treat the diabetes. Failing to notify the doctor of the abnormal labs was a form of nursing home abuse and neglect.
Past the immediate serious medical conseuqences of failing to treat this resident’s diabetes, there are the longer-term implications of having diabetes untreated for that length of time. It can help complicate wound healing in residents who suffer from bed sores. Diabetes can have adverse effects on a resident’s vision which can increase the risk of a nursing home falls.
This is a case which speaks to a significant systems failure at this nursing home. Obtaining labs and reporting back on the results of them are one of the very basic things that are done on a day to day basis at a nursing home. Here, there were multiple tests which “slipped through the cracks” to the point that there were not even reports in the resident’s chart. It also brings into focus the role of the lab, an outside vendor – what proof do they have of the delivery of the lab reports?
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