Failure to Complete Ordered Diabetes Lab Monitoring
Penalty
Summary
The facility failed to ensure that a resident with diabetes mellitus received Hemoglobin A1C (HgA1C) testing every three months as ordered by the physician. The resident, who was dependent on staff for dressing and bathing and had a care plan indicating a risk for hypoglycemia or hyperglycemia, had a physician's order dated 2/27/2024 for quarterly HgA1C testing. However, a review of laboratory results showed that the test was completed on 8/16/2024 and 3/25/2025, but not on 6/25/2025 as required by the order. During an interview and record review, an LVN confirmed that the HgA1C test was not completed as ordered and acknowledged that the test was necessary to monitor the resident's diabetes status. The facility's policy required that diagnostic orders be promptly carried out as instructed by the physician, but this was not followed in this case, resulting in inadequate monitoring of the resident's diabetes.