Failure to Obtain Ordered Fasting Serum Blood Sugars for Diabetic Resident
Penalty
Summary
The facility failed to obtain fasting serum blood sugars (FSBS) as ordered for one resident with diabetes and diabetic neuropathy. Upon admission, the resident had hospital discharge orders for daily insulin injections and FSBS monitoring. A revised care plan also indicated the need for FSBS to be completed as ordered. However, diabetic administration records for two consecutive months showed no documented FSBS results for this resident. The resident reported that FSBS were rarely monitored, and staff interviews confirmed that the hospital discharge order for FSBS was missed during the admission process. Staff also indicated that FSBS were typically obtained weekly for diabetic residents, and nurse managers were expected to review new resident orders within 24 hours to ensure accuracy.