Failure to Document Blood Sugar Rechecks and Physician Notification for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that sufficient information related to a resident's blood sugar was rechecked and that physician notification and verbal orders were properly documented in the clinical record. The resident in question had diagnoses including type 2 diabetes mellitus, sepsis, and hyperglycemia, and was on a sliding scale insulin regimen with specific instructions to notify the physician and recheck blood sugar if levels exceeded 400 mg/dL. On multiple occasions, the resident's blood sugar readings were above 400 mg/dL, but the clinical record lacked documentation of a timely recheck, confirmation that the physician or nurse practitioner was notified, or that verbal orders were received and recorded as required. Nursing notes indicated attempts to contact the physician and nurse practitioner, as well as instructions from the DON to administer insulin and recheck the blood sugar. However, there was no documentation in the medical record confirming that the nurse practitioner was notified, that a recheck was performed, or that a verbal order was received and documented. Interviews with staff confirmed these documentation gaps, and the facility's policy required real-time charting and documentation of resident status and changes, which was not followed in this instance.