Incomplete Documentation of Insulin Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident receiving insulin for type 2 diabetes mellitus with hyperglycemia. Specifically, review of the resident's physician order indicated that blood sugar checks and insulin administration were to be documented according to a sliding scale protocol. However, the Medication Administration Record (MAR) showed missing documentation for both blood sugar readings and insulin coverage on two separate occasions. Interviews with nursing staff revealed that while they recalled performing the required blood sugar checks and insulin administration, they could not explain why the documentation was left blank. The Director of Nursing confirmed that staff are expected to document medication administration accurately and as required. Facility policies on medication administration and charting require that all medications administered and services performed be documented in the resident's clinical record or MAR. Despite these policies, the required documentation was not completed for the resident on the specified dates, resulting in incomplete medical records. The deficiency was identified through observation, interview, and record review, confirming that the facility did not adhere to its own documentation standards for medication management.