Failure to Document Hypoglycemic Episode
Penalty
Summary
A deficiency occurred when the facility failed to document an episode of hypoglycemia for a resident with type 2 diabetes mellitus. The resident was admitted with orders for fingerstick blood sugar checks before meals and at bedtime, with instructions to notify the physician if levels were below 80 or above 400. On the day in question, the resident experienced symptoms of low blood sugar, which was confirmed by an LPN who measured a blood sugar level of 61. The LPN administered orange juice and sugar, and a subsequent check showed the blood sugar had risen to 91. Despite this event, there was no documentation of the incident in the resident's electronic medical record. Interviews with the resident, the LPN involved, and the Assistant Director of Nursing (ADON) confirmed that the hypoglycemic episode occurred and that it was not documented. The ADON and facility administration both stated that it was their expectation for such episodes to be documented according to current standards of practice. The lack of documentation was verified through review of the entire electronic medical record and direct staff interviews.