Incomplete Documentation of PRN Antidiabetic Medication Administration
Penalty
Summary
The facility failed to ensure that medical records for a resident receiving antidiabetic medication were complete and accurate. Physician orders required blood sugar monitoring every 12 hours and administration of glipizide as needed when blood sugar exceeded 180. Review of the resident's Medication Administration Records (MAR) for two consecutive months showed multiple instances where blood sugar readings were above the threshold, but there was no documentation of glipizide administration or refusal. Interviews with nursing staff revealed confusion regarding where to document the administration of PRN glipizide, with some staff indicating they may have documented in the wrong area or could not recall specific events. The Director of Nursing acknowledged this confusion among staff regarding documentation procedures for PRN medications. The resident in question had a history of diabetes mellitus and was described as frequently non-compliant with her antidiabetic medication, often refusing both oral and injectable treatments. Despite this, the facility's policy required immediate and accurate documentation of all medication administrations, including PRN medications, specifying the need to record the date, time, dose, and route. The lack of documentation on the MAR for multiple dates where blood sugar was elevated and glipizide should have been administered or refused constituted a failure to maintain complete and accurate medical records in accordance with professional standards.