Failure to Maintain Accurate Clinical Records for Insulin Administration
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain accurate and complete clinical records for a resident with multiple diagnoses, including COPD and diabetes. The resident's medical record contained outdated physician orders, specifically regarding insulin administration. Although the resident was no longer receiving sliding scale insulin due to refusal of injections and had been placed on long-acting insulin, the clinical record was not updated to reflect the current physician's order. The Director of Nursing confirmed that the record should have been updated to match the resident's current treatment regimen.