Failure to Monitor Blood Glucose as Ordered
Penalty
Summary
The facility failed to ensure that nurses followed physician's orders to monitor fingerstick blood glucose levels for a resident with diabetes mellitus, among other conditions. The resident, a male admitted from an acute care hospital, required insulin injections and had specific orders for blood glucose monitoring and insulin administration. On a particular day, an LPN was unable to locate the resident's Lispro insulin and contacted the physician, who instructed to hold the insulin and re-check the resident's blood glucose every hour until the refill arrived. However, the LPN did not document any re-checks during her shift, and the next recorded blood glucose measurement was taken four hours later by another LPN. The Unit Manager confirmed the lack of documentation for the hourly re-checks as per the physician's orders, and the Director of Nursing emphasized the importance of following doctor's orders to prevent complications. The facility's standards required nurses to evaluate and document the resident's status, which was not adhered to in this instance. This oversight in monitoring and documentation led to a deficiency in the care provided to the resident, as the facility did not ensure proper management of the resident's diabetes condition.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On an assessment was completed on resident number 93 no signs or symptoms of hyper or were noted. b. On Staff member received education on entering physician orders in the medical record when received orders for abnormal lab results. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On the Director of Nursing/designee completed an audit to ensure resident with order changes related to abnormal results ensure all orders are followed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/designee completed education with licensed nurses when orders are received related to abnormal results a physician order is placed in the resident medical record. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure resident with order changes related to abnormal results ensure all orders are followed compliance with federal regulation F684 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.