IDPH has cited and fined The Pearl Of Joliet when the facility failed to properly monitor and manage the blood glucose levels of a resident with a history of Diabetic Ketoacidosis and elevated blood sugars. This failure resulted in the resident requiring hospitalization for Diabetic Ketoacidosis.
The male resident was admitted to the facility after suffering a cardiac arrest and being diagnosed with Diabetic Ketoacidosis (DKA) in the emergency room. At that time, his blood sugar level was extremely high at 1229 mg/dL.
The facility’s Medication Administration Record (MAR) indicated that the resident’s blood sugar level was to be monitored three times daily, at 7:30 AM, 12:00 PM, and 4:30 PM. The resident was prescribed Insulin Aspart 35 units twice daily and 15 units at noon, as well as a sliding scale insulin regimen based on his blood sugar results.
However, the facility failed to adequately monitor and respond to the resident’s consistently elevated blood sugar levels. Approximately a week after being admitted, the resident’s blood glucose readings ranged from 345 mg/dL to 400 mg/dL, despite the routine insulin doses and sliding scale orders.
The facility staff did not document rechecking the resident’s sugar after dinner and at bedtime, nor did they monitor him for changes in condition. Furthermore, there was no documentation of notifying the resident’s physician about the consistently high blood sugar levels.
Eight days after admittance, at 6:15 AM, the resident’s blood sugar level spiked to 600 mg/dL.
Later that morning, the resident was found on the floor, displaying lethargy and slurred speech. His blood sugar level was so high it simply read “HI” on the glucometer. The resident was subsequently sent to the hospital emergency department.
Upon admission to the hospital the resident’s blood glucose level was 810 mg/dL, and his ketone level was very high at 5.7 mmol/L, confirming the diagnosis of Diabetic Ketoacidosis.
The resident’s physician stated, “For brittle diabetics, the standard glucose monitoring is 3-4 times a day, and as needed. When the resident’s glucose level was consistently elevated despite administration of prescribed insulin, the staff should have rechecked the sugar 2 hours after dinner and rechecked it again at bedtime. If there was no order, the staff should have called me.” The physician added that when blood sugar is consistently elevated, “the staff should follow up with the physician, and closely monitor resident’s condition and sugar level.”
This incident highlights a significant failure in the facility’s diabetes management protocol, potentially endangering the resident’s health and leading to a preventable hospitalization. The staff’s failure to properly monitor blood glucose levels, adjust treatment, and communicate with the physician resulted in a severe case of Diabetic Ketoacidosis that required intensive care.
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