Failure to Monitor Blood Glucose After Resident's Absence
Penalty
Summary
A deficiency occurred when the facility failed to measure a resident's blood sugar upon their return after an absence of approximately 24 hours. The resident, who had diagnoses including diabetes mellitus, hypertension, hyperlipidemia, and dementia, was prescribed insulin and oral medication for diabetes management. After being admitted, the resident left the facility without authorization and was missing for about a day. Upon being located and returned to the facility, the resident was provided a meal, but licensed staff did not check the resident's blood glucose level before the meal, despite the resident's risk for hypoglycemia or hyperglycemia due to missed medications and prolonged absence. Interviews with nursing staff and the Director of Nursing confirmed that blood sugar should have been measured upon the resident's return, in accordance with the facility's policy for residents receiving insulin who have had a significant absence. The failure to perform this assessment was not in line with professional standards of practice and the facility's own procedures for managing residents with diabetes.
Plan Of Correction
F-684 Immediate Corrective Action: On 04/26/2025, the Director of Nurses followed up with General Acute Hospital regarding resident's condition. Obtained information that resident was medically clear at Emergency Department and was admitted at Gero-psychiatric floor for further evaluation as gravely disabled. Based on ER records, resident blood sugar level was within normal range. Action taken to identify all other residents having the potential to be affected by the deficient practice and corrective action taken: On 04/27/2025, ADON and RN supervisor reviewed all diabetic residents' charts who required blood sugar check via fingerstick. All residents' blood sugar via fingerstick were checked as ordered. No other residents were affected by the same deficiency practice. Process and action taken to ensure deficient practice does not reoccur: On 04/27/2025, the Director of Nurses conducted an in-service with the licensed nurses on the importance of checking blood sugar level via fingerstick for residents with diagnosis of diabetes to prevent occurrence of hypoglycemia and to manage episodes of hyperglycemia. Additionally, on 04/27/2025, the DON conducted a 1:1 in-service with RN1 regarding the emphasis of checking blood sugar via fingerstick for residents with diagnosis of diabetes to prevent episodes of hypoglycemia and manage episodes of hyperglycemia. Monitoring performance to ensure that correction is achieved and sustained: The ADON/RN supervisor will randomly review residents' charts with diagnoses of diabetes to ensure that blood sugar check via fingerstick is done as ordered by MD. The ADON/RN supervisor will check charts of residents with diagnosis of diabetes every week for 3 months to ensure that all orders for fingerstick are followed as ordered by MD. As part of the facility CQI program, the DON will present a recapitulation of the RN supervisor's findings, which will be reviewed by the QAA committee monthly for the next three months for review and action as indicated. The DON will monitor compliance through review of monthly reports by the RN supervisor and ADON.