JOHNSTON, IA - State health inspectors found that Bishop Drumm Retirement Center staff failed to notify medical providers when a diabetic resident's blood sugar reached dangerous levels exceeding 400, waiting days before seeking medical intervention despite facility protocols requiring immediate physician notification for such critical readings.
Critical Delays in Medical Communication
The inspection, conducted on May 29, 2025, revealed that Resident #2, who is under the care of a local hospital's residency group, experienced blood sugar levels above 400 without staff alerting any medical provider. The facility's Director of Nursing acknowledged during the investigation that she would expect staff to notify a provider anytime a resident's blood sugar exceeds 400, with some staff taking action at levels around 350.
Review of progress notes confirmed that no provider notification occurred prior to April 17, 2025, despite the resident experiencing dangerously elevated glucose levels before that date. This delay in medical communication potentially exposed the resident to serious diabetic complications.
Medical Director Confirms Protocol Breach
The facility's Medical Director emphasized the severity of the communication breakdown when interviewed by inspectors. He stated that while Resident #2 is primarily followed by the Hospital Residency Group, staff should contact either that group or himself whenever resident safety concerns arise.
"If there is a concern for the safety of any resident, he would want the staff to call himself or whoever is on call for him," the inspection report noted. The Medical Director indicated that in this case, he would have immediately contacted the Residency Group to ensure the resident received appropriate care.
Understanding the Medical Risks
Blood sugar levels exceeding 400 mg/dL represent a medical emergency requiring immediate intervention. At these levels, residents face increased risk of diabetic ketoacidosis (DKA), a life-threatening condition where the body produces excess blood acids. Without prompt treatment, high blood sugar can lead to severe dehydration, confusion, loss of consciousness, and potentially diabetic coma.
Standard medical protocols dictate that blood glucose readings above 400 require immediate physician notification to adjust insulin dosing, evaluate for underlying infections or illness, and potentially initiate emergency treatment. The delay in notifying providers meant Resident #2 went without crucial medical adjustments during a period of dangerously uncontrolled diabetes.
Systemic Communication Failures Identified
The investigation revealed broader systemic issues with the facility's provider notification procedures. The Director of Nursing admitted there were no clear parameters established regarding when providers should be notified about changes in vital signs or blood sugar levels. This lack of standardized protocols left critical medical decisions to individual staff judgment, creating dangerous inconsistencies in care delivery.
The absence of sliding scale insulin orders for Resident #2 further complicated diabetes management. Sliding scale protocols allow nurses to administer insulin based on current blood sugar readings without waiting for physician orders, enabling more responsive glucose control.
Corrective Actions and Industry Standards
Following the inspection, the Director of Nursing outlined several corrective measures. The facility committed to obtaining specific parameters from medical providers regarding notification thresholds for vital signs and blood sugar changes. Staff will receive updated education on proper notification procedures, and the facility will implement a change of condition form within their electronic health charting system.
Industry standards require nursing homes to maintain clear communication protocols with medical providers, particularly for residents with chronic conditions like diabetes. Facilities should have standing orders or parameters that eliminate ambiguity about when to contact physicians. Most facilities implement notification protocols requiring immediate physician contact for blood sugars above 350-400 mg/dL, with many using lower thresholds for residents with unstable diabetes.
The facility also plans to obtain sliding scale insulin orders for Resident #2, bringing their diabetes management in line with standard practices that enable nurses to respond quickly to blood sugar fluctuations.
The inspection classified this violation as causing "minimal harm or potential for actual harm" affecting few residents, though the potential consequences of unmanaged high blood sugar could have been far more severe. The facility's delayed response to critical glucose levels and lack of clear notification protocols represent fundamental breakdowns in resident safety systems that require immediate remediation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bishop Drumm Retirement Center from 2025-05-29 including all violations, facility responses, and corrective action plans.
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