Failure to Document Rationale for Discontinuing Blood Sugar Monitoring in Insulin-Dependent Residents
Penalty
Summary
The facility failed to provide a documented rationale for discontinuing blood sugar monitoring for six residents who were insulin dependent. Clinical record reviews and staff interviews revealed that blood sugar check orders were discontinued for these residents while they continued to receive insulin, without any documentation in the residents' progress notes explaining the clinical reasoning for this decision. Both the Assistant Director of Nursing and the Director of Nursing confirmed that there was no facility policy regarding the discontinuation of blood sugar checks for residents with diabetes who are on insulin, and that practitioners are required to document the clinical reasoning when discontinuing such orders, which was not done in these cases. Further, the Medical Director was not aware that blood sugar check orders were being discontinued for residents with standing insulin orders and stated that regular blood sugar checks are necessary regardless of trends. The Facility Administrator also confirmed that a progress note should have been placed when modifying or discontinuing blood sugar checks after reviewing and confirming the orders with the physician. The lack of documentation and absence of a facility policy led to the deficiency, as there was no evidence in the clinical records to support the discontinuation of blood sugar monitoring for these insulin-dependent residents.