Failure to Monitor and Document Blood Glucose per Physician Order
Penalty
Summary
Staff failed to monitor and document a resident's blood glucose according to the physician's order. On the morning in question, a Licensed Practical Nurse (LPN) checked the resident's blood glucose after the resident had already eaten most of her breakfast, rather than before the meal as ordered. The glucometer reading at that time was 309. The Medication Administration Record (MAR) for that day inaccurately documented the blood glucose as 144 at 7:30am, despite the actual check occurring later and yielding a much higher result. The LPN acknowledged that the blood glucose should have been checked before breakfast, and the Director of Nursing confirmed that staff are expected to perform the check prior to meal service to ensure accurate readings. The resident involved had diagnoses including hypertension, chronic pain, and Type 2 Diabetes Mellitus, with active orders for blood glucose monitoring before meals and at bedtime. Facility policy also required blood glucose monitoring to be performed and documented per physician's orders. Interviews with staff and review of records confirmed that the blood glucose was not checked at the correct time and that the result was not accurately documented, which could impact the management of the resident's diabetes.