Failure to Follow Physician Orders for Blood Glucose Monitoring and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents regarding blood glucose monitoring and medication administration. One resident with a diagnosis of diabetes was admitted with orders for capillary blood glucose (CBG) checks three times daily, as indicated in both the hospital after-visit summary and a nurse practitioner note. Despite these orders and the resident's report of frequent CBG monitoring at home, the clinical record showed that staff did not perform or document any CBG monitoring after admission. Multiple staff interviews confirmed that the orders for CBG monitoring were entered into the electronic record but were not implemented by nursing staff. Another resident with a diagnosis including herpes virus infection had a physician order for acyclovir to be administered twice daily as needed for a herpes outbreak. Review of the medication administration record (MAR) revealed that the resident received acyclovir only once daily, except for one day when it was given twice. Staff confirmed that the medication was administered only when the resident requested it, rather than according to the prescribed twice-daily schedule.