Failure to Provide Diabetes Management and Monitoring
Penalty
Summary
A resident with a history of diabetes mellitus was admitted to the facility and subsequently exhibited significantly elevated blood glucose levels and A1C values on multiple occasions. Despite these abnormal laboratory results, there was no documented intervention, nursing action, or medical orders to address the elevated blood glucose and A1C. The resident was later hospitalized for altered mental status and diagnosed with diabetic ketoacidosis, encephalopathy, and a urinary tract infection. Upon readmission, the resident's diabetes diagnosis was not reflected in the Minimum Data Set (MDS), care plan, or medication administration record, and no blood glucose monitoring or diabetes medications were provided. Interviews with staff revealed a lack of awareness of the resident's diabetic status, and chart checks intended to identify such issues were not consistently performed. Orders for insulin and blood glucose monitoring were present in the physical chart but were not carried out by nursing staff. The nursing admission screening did document new onset diabetes, but this information was not integrated into the resident's ongoing care. The deficiency resulted from failures in communication, documentation, and adherence to physician orders, leading to the resident not receiving necessary diabetes management.