Failure to Document Insulin Administration and Wound Care
Penalty
Summary
The facility failed to properly document blood glucose levels and insulin administration for a resident with a diagnosis of type 2 diabetes mellitus. Physician orders required glucose monitoring before meals and at bedtime, as well as administration of Insulin Lispro before meals and Insulin Glargine at bedtime. On a specific date, there was no documentation of the resident's blood glucose levels or the administration of either insulin at the required times. During an interview, an LPN admitted to forgetting to document these actions after working a double shift. The DON confirmed that the expectation is for nurses to document glucose levels and medication administration accurately and in real time. Additionally, the facility failed to accurately document wound care for the same resident. Although the resident had a physician order for wound care to the left lateral malleolus, the wound was documented as resolved on a specific date. The treatment record for April showed multiple blank entries on days when wound care should have been provided, and on one occasion, a nurse checked off that wound care was completed when it was not. Both the DON and the wound care nurse acknowledged that the wound order should have been discontinued once the wound healed, and that documentation should only reflect care that was actually provided. Facility policies require accurate documentation of treatments and services performed.