Failure to Consistently Complete and Document Daily Glucometer Controls
Penalty
Summary
The facility failed to ensure that glucometer quality controls were consistently completed as required. During a medication storage observation, it was found that the March 2025 Quality Control Record sheet for a medication cart showed that glucometer controls were not performed on several specific dates throughout the month. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed during interviews that glucometer controls should be performed daily by the night shift and documented accordingly, but acknowledged that this was not done consistently in March 2025. The DON attributed the inconsistency to new and temporary nursing staff and staff turnover. Facility policy requires that glucometers be calibrated at least once daily, with results recorded on the appropriate form kept in the glucometer logbook at the nurses' station. Review of the clinical records, facility documentation, and staff interviews confirmed that this policy was not followed, resulting in incomplete documentation and inconsistent performance of required glucometer controls.