Failure to Monitor Blood Glucose as Ordered for New Admission
Penalty
Summary
A deficiency occurred when the facility failed to monitor and document blood glucose levels as ordered by the physician for a newly admitted resident with multiple diagnoses, including type II diabetes mellitus, acute kidney failure, chronic kidney disease stage five, myocardial infarction, hypertension, vitreous hemorrhage, glaucoma, and anemia. The resident was admitted with physician orders from the hospital discharge, specifically directing the use of a glucometer and glucose blood test strips to monitor blood sugar three times daily and as needed. The nursing plan of care also included interventions to monitor blood sugars as ordered by the physician. Despite these orders and the resident's history of daily blood sugar monitoring and insulin administration based on sliding scale, review of the medical record revealed no documented evidence that blood glucose monitoring had been performed since admission. Interviews with the resident, an LPN, and the DON confirmed that no daily blood glucose monitoring or related insulin coverage was documented or performed until the surveyor's inquiry, at which point a blood sugar reading was obtained. The DON verified that the physician's orders for daily blood sugar monitoring were present but had not been carried out since admission.