Failure to Document and Verify Blood Sugar Readings for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified during a recertification survey, where it was observed that a resident with a diagnosis of type 2 Diabetes Mellitus did not have a physician's order for the use of a Freestyle Libre device, which was used to monitor their blood glucose levels. The resident was admitted from the hospital with this device, but the order for its use was not documented in the facility's records. During a medication administration task, an LPN administered insulin to the resident without verifying the blood sugar level on the Freestyle Libre device, relying solely on the resident's verbal report of their blood sugar reading. Interviews with the nursing staff and the Director of Nursing revealed that the LPNs were expected to verify blood sugar readings on the device before administering insulin. The primary physician for the resident was unaware that an order for the device had not been placed initially and only rectified this after being informed of the oversight.
Plan Of Correction
Plan of Correction: Approved April 8, 2025 Corrective Actions for Residents Identified - For Resident # 40, RN reviewed the blood sugar levels; there were no negative outcomes from the deficient practice as evidenced by the stable blood sugar levels between 122 and 301. - Licensed Practical Nurse #3 was in-serviced on Medication Administration with an emphasis on the verification of blood sugar prior to Insulin injection on (MONTH) 14, 2025. - Registered Nurse # 3 was in-serviced on Medication Order Reconciliation policy on (MONTH) 14, 2025. - The order for Continuous Glucose Monitoring device was reviewed and revised on (MONTH) 14, 2025. Residents At Risk - All residents receiving Insulin injections have the potential to be affected by this practice. - An audit of all residents receiving Insulin injections admitted in the past 3 months is being done to ensure all orders are reconciled and accurate. Any outstanding findings will be addressed immediately. Systemic Changes - The policy and Procedure “Medication Order Reconciliation” was reviewed by DNS on (MONTH) 14, 2025, and no revision needed. - The policy and procedure titled “Medication Orders” was reviewed by DNS on (MONTH) 14, 2025, and no revision needed. - All nurses are being in-serviced by the ADNS on “Medication Order Reconciliation” and “Medication Orders” Policies. - All nurses are being in-serviced by the ADNS on “Personal Glucose Monitoring Devices and Continuous Glucose Monitoring (CGM) System” policy and procedures. - “Use of Personal Glucose Monitoring Devices and Continuous Glucose Monitoring (CGM) System” policy and procedure was developed and is being implemented. The procedure includes specific steps for nurses to follow to ensure the blood glucose readings are verified prior to Insulin administration. - The medication administration competency observation was revised; Continuous Glucose Monitoring System was added. - The audit tool was developed for monitoring compliance. Monitoring Of Corrective Actions - On a weekly basis for one quarter, ADNS or designee will audit new admission/re-admission orders [REDACTED]. - Any outstanding issues will be addressed immediately and reported to DNS. - On a weekly basis for one quarter, ADNS or designee will interview and observe, when applicable, 2-4 nurses for competency with Continuous Glucose Monitoring System. - On a monthly basis, ADNS or designee will report findings to DNS. - On a monthly basis, DNS or designee will report findings to Administrator. - On a quarterly basis, DNS or designee will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. Responsible party: Director of Nursing