Failure to Accurately Document Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure appropriate and accurate documentation in the electronic medical records for a resident with diabetes and atherosclerotic heart disease. The resident was admitted with orders for Lantus insulin, which was later adjusted, but did not have routine blood sugar checks ordered. On one occasion, the resident experienced critically high blood sugar readings, and a series of orders were given by a nurse practitioner to administer multiple doses of Humulin insulin and to recheck blood sugars. The progress note documenting these events did not include the times of provider notification, when orders were received, the times of insulin administration, or the times of blood sugar rechecks. Further review revealed that none of the Humulin doses administered were entered into the electronic medical record or recorded on the Medication Administration Record (MAR). Interviews with the resident, the LPN involved, the DON, and the nurse practitioner confirmed that the insulin orders and administrations were not properly documented in the electronic system, and that facility policy required blood glucose monitoring results to be recorded in the MAR. The lack of documentation affected the accuracy and completeness of the resident's medical record.