Failure to Follow Physician Orders for Blood Sugar Monitoring and Post-Death Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders and professional standards for a resident with multiple complex medical conditions, including respiratory failure, ventilator dependence, and type II diabetes mellitus. Specifically, the resident's physician ordered finger stick blood sugar (FSBS) monitoring every 12 hours at 6 a.m. and 6 p.m., with insulin administration as needed per a sliding scale. However, a nurse performed the blood sugar check at 12 p.m., not at the times specified in the physician's order, and did not administer insulin, citing nursing judgment due to the resident being on tube feeding. This deviation from the prescribed monitoring schedule was confirmed by both the nurse involved and a reviewing RN, who noted that the physician's order was not followed and there was no clinical indication for an unscheduled blood sugar check. Additionally, the facility did not follow its own policy and procedure regarding documentation after a resident's death. When the resident expired, there was no death certificate on file in the medical record, and the attending physician had not documented the cause of death in the progress notes as required. The facility's policy mandates that the attending physician must record the cause of death and complete and file a death certificate within 24 hours or as prescribed by state law, but this was not done.