Failure to Ensure Blood Sugar Monitoring Orders for Resident Receiving Insulin
Penalty
Summary
The facility failed to ensure that laboratory tests, specifically blood sugar monitoring, were conducted in accordance with professional standards for one resident with type 2 diabetes who was receiving daily insulin injections. Review of the resident's admission record and physician's orders confirmed an active order for daily Tresiba insulin injections, but there was no corresponding order for daily blood sugar checks. The resident's Minimum Data Set assessment also documented insulin administration on each day of the look-back period, yet lacked evidence of blood sugar monitoring orders. Interviews with nursing staff, including an LPN, the DON, and the Administrator, verified that the resident was receiving insulin without an order for blood sugar checks. Staff acknowledged that physician orders should include blood sugar monitoring for residents on insulin, and that it was the responsibility of nurses and management to ensure such orders were in place. The absence of these orders was confirmed through both record review and staff interviews.