Incomplete and Inaccurate Medical Record Documentation for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident's medical records were complete and accurate, specifically for a resident with type 2 diabetes mellitus and a foot ulcer. Physician orders required blood glucose monitoring before meals and at bedtime, and the use of a glucagon emergency injection kit if blood sugar dropped below 60, with rechecks every two hours. On one occasion, the resident experienced low blood sugar, received oral glucose gel, and later glucagon was administered per on-call provider instructions. However, there was no documentation of a physician's order for the glucose gel, nor was there documentation that the physician was notified of the low blood sugar event and the administration of glucose gel. Additionally, blood sugar checks were not consistently documented, including post-administration values after glucagon was given. Interviews with the LPN involved revealed that blood sugar was checked more frequently than documented, and the Director of Nursing confirmed that documentation was incomplete, particularly regarding post-intervention blood sugar levels. Facility policies required that all medication administration, changes in condition, and interventions be documented in the clinical record, but these requirements were not met in this case. The lack of complete and accurate documentation constituted a failure to maintain medical records in accordance with accepted professional standards.