Failure to Maintain Accurate Medical Records for Insulin Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for four residents who were receiving insulin therapy for diabetes management. For one resident, there were discrepancies in the Medication Administration Record (MAR), including missing or inaccurate documentation of blood sugar levels and insulin administration, as well as a lack of documentation regarding physician notifications when insulin was held or when the resident declined insulin. Staff interviews revealed that insulin was sometimes administered without proper documentation, and in some cases, staff did not record communications with physicians as required by facility policy. Another resident's records showed missing entries for insulin administration and blood sugar monitoring, with no documentation of provider notification when insulin was held due to low blood sugar. Staff interviews indicated that insulin was sometimes held based on clinical judgment, but the required documentation and provider communication were not consistently recorded in the medical record or progress notes. The physician expected to be notified when insulin was held, but there was no evidence of such notifications in the records reviewed. Additional residents had similar issues, including failure to document provider notifications when blood glucose readings exceeded parameters outlined in physician orders, and instances where insulin was administered or held without appropriate documentation or explanation. Facility policy required immediate documentation of medication administration or refusal, as well as documentation of any communication with providers regarding changes in medication administration. These requirements were not consistently followed, resulting in incomplete and inaccurate medical records for the residents involved.