Failure to Document Interventions for Hypoglycemic Event
Penalty
Summary
The facility failed to document the interventions provided to a resident who experienced hypoglycemia, with a recorded blood sugar level of 37. The resident, who had a diagnosis of diabetes mellitus and the capacity to make decisions, was admitted to the facility and had a low blood sugar event documented in the Medication Administration Record and SBAR form. While the physician was notified of the hypoglycemic event, there was no documentation in the medical record indicating what interventions, if any, were provided to address the low blood sugar. Interviews with nursing staff revealed that standard practice for blood sugar levels of 70 or below included providing orange juice or glucagon and notifying the physician. One LVN stated she gave orange juice and rechecked the blood sugar, but admitted she did not document these actions. The Director of Nursing confirmed that all interventions should be documented according to facility policy, which requires monitoring and documenting the resident's progress and response to treatment. The lack of documentation made it unclear what care was provided during the hypoglycemic episode.