Failure to Monitor Blood Glucose and Meal Intake for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to monitor blood glucose levels, assess meal intake, and ensure proper communication among staff for a newly admitted resident with diabetes. The resident, who had a history of type 2 diabetes mellitus with ketoacidosis, chronic kidney disease stage 3, and a below-knee amputation, was admitted without documentation of baseline blood glucose or oral intake. The clinical admission form lacked this essential information, and the physician's order specified insulin administration before breakfast. On the morning following admission, the resident received insulin at 7:00 a.m. with a recorded blood glucose of 99. Shortly after, the resident was found unresponsive with a critically low blood sugar of 25. Emergency interventions included administration of glucagon and orange juice, which gradually improved the resident's condition. Interviews with nursing staff revealed that there was no communication regarding the resident's last meal or baseline blood glucose, and the assigned nurse was unaware of whether the resident had eaten prior to insulin administration. Facility policy required documentation of blood glucose levels and meal intake for diabetic residents, as well as communication of this information among staff. Multiple staff members, including the DON, confirmed that these steps were not followed. The lack of documentation and communication led to the administration of insulin without confirming food intake, resulting in a hypoglycemic event for the resident.