Failure to Complete Blood Glucose Testing per Physician Orders
Penalty
Summary
The facility failed to ensure that blood glucose testing (BGT) was completed according to physician orders for a resident with diagnoses including encephalopathy, type 2 diabetes, and dementia. The resident had physician orders for sliding scale insulin coverage, which required BGT to be performed before meals and at bedtime. However, documentation revealed that on two occasions, BGT was performed after the resident had already consumed breakfast, rather than prior to the meal as ordered. This was confirmed by both the Medication Administration Record and staff interviews. The resident's power-of-attorney had requested that the resident not be woken up during the night or for breakfast, and that medication administration times be adjusted to when the resident was awake. Staff reported that on the days in question, the resident either woke up on their own or was awakened by family and began eating before staff realized, resulting in BGT being performed after meal consumption. The Director of Nursing confirmed that BGT was completed after breakfast on these dates, contrary to the physician's orders.