Failure to Monitor and Manage Blood Glucose Levels in Diabetic Residents
Penalty
Summary
The facility failed to adequately assess, monitor, and control blood glucose levels for two residents with diabetes. For one resident, blood sugar monitoring and sliding scale insulin coverage were discontinued based on pharmacy recommendations, and although blood glucose levels remained consistently elevated, no further adjustments to insulin dosages were made after a certain date. Documentation showed that the majority of blood glucose readings were above the normal range, and communications regarding high blood sugar levels did not result in changes to the treatment plan. The resident reported that their blood sugars were out of control but had not discussed this with staff, and the nurse practitioner was unaware of the ongoing elevated levels. For another resident, there was a lack of ongoing blood sugar monitoring despite a history of worsening diabetes and hospital discharge instructions to continue both sliding scale and long-acting insulin with tight glycemic control. After an initial period of frequent blood sugar checks, documentation of blood glucose monitoring ceased, and there were no active orders for blood sugar checks or sliding scale insulin. The resident's care plan included monitoring glucose levels, but this intervention was not consistently implemented. Staff interviews confirmed that blood sugar checks were not being performed, and the facility did not have a policy for insulin sliding scale or diabetes/insulin orders.