Failure to Administer Diabetes Management as Ordered
Penalty
Summary
The facility failed to ensure that three residents with diabetes mellitus received blood sugar monitoring, insulin, and hypoglycemic medications as ordered by their physicians. For one resident, multiple instances were documented where blood sugar levels were not obtained at scheduled times, and insulin was either not administered or marked as refused without corresponding blood sugar results. In several cases, the Medication Administration Record (MAR) indicated that blood sugar monitoring was not completed or not documented, and insulin doses were coded as non-applicable or refused without supporting evidence. The Director of Nursing (DON) and Corporate RN Consultant confirmed that blood sugar results were not available for the dates in question, and the resident was later transferred to the hospital. Another resident's records showed that blood sugar monitoring was scheduled four times daily, but the MAR reflected that monitoring was marked as completed without actual results documented for numerous days. The Corporate RN Consultant acknowledged the lack of documentation for blood sugar results prior to a certain date. A third resident's records indicated missed blood sugar monitoring and missed administration of Metformin, a hypoglycemic medication, on several occasions. The DON was unable to verify that blood sugar testing or medication administration had been completed as ordered. These findings were confirmed through record review and staff interviews.