Failure to Perform Blood Glucose Monitoring as Ordered
Penalty
Summary
The facility failed to follow physician orders and its own policy regarding blood glucose monitoring for three residents with diabetes. Nursing staff did not consistently check blood sugar levels before meals as ordered by the physicians. Interviews with nursing staff revealed that blood sugar checks were missed or delayed, often occurring after residents had already eaten breakfast. One nurse reported being distracted by other duties and losing track of time, while another cited technical issues such as loss of internet connection. In some cases, residents refused blood sugar checks after eating, and the missed checks were not documented with reasons in the medical record as required by facility policy. Record reviews confirmed that blood glucose monitoring was not performed at the times specified in the physician orders for all three residents. The electronic medication administration records and blood sugar summary sheets showed that blood sugar checks were recorded later than the ordered times or were missed entirely. The residents involved had diagnoses of type 2 diabetes and were alert and oriented, with physician orders specifying blood sugar checks before meals and at specific times throughout the day. The facility's policy required that all physician orders be followed as prescribed and that any deviations be documented, which was not done in these cases.