Failure to Monitor Blood Glucose and Ensure Continuity of Diabetes Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including type 2 diabetes mellitus, was not provided with appropriate blood glucose monitoring and continuity of diabetes medication administration upon admission. The resident was admitted with orders for blood glucose monitoring and several diabetes medications, including insulin and oral agents. Despite these orders, there was only one documented blood sugar reading on the day of admission, with no further monitoring recorded until a week later. During this period, the resident received diabetes medications, including insulin and oral agents, without concurrent blood glucose monitoring as ordered. Interviews with nursing staff and facility leadership confirmed that blood glucose monitoring should have been performed according to physician orders, especially for residents receiving insulin. Staff acknowledged that monitoring is necessary to safely administer insulin and oral diabetes medications and to detect abnormal blood sugar levels that require intervention. The Director of Nursing and Assistant Director of Nursing both stated that the expectation is to follow physician orders for blood glucose checks and that such monitoring is critical for diabetic residents, particularly those on insulin therapy. Record review showed that the resident was administered diabetes medications, including Lantus Insulin Glargine and Empagliflozin, before blood glucose monitoring was initiated. Additionally, an ordered insulin (Semglee) was not administered due to a delay in pharmacy supply. The lack of blood glucose monitoring and incomplete medication administration represented a failure to provide appropriate care and management for the resident's diabetes as ordered and as required by facility policy.