Failure to Follow Physician Orders for Blood Sugar and Blood Pressure Monitoring
Penalty
Summary
The facility failed to follow physician's orders for blood sugar monitoring and management for two residents and for blood pressure monitoring for one resident. For one resident with end stage kidney disease and diabetes mellitus, there were multiple instances where blood sugar readings were below the physician-ordered threshold, but there was no documented evidence that the physician was notified, that a rapidly absorbed glucose was provided, or that blood sugar was rechecked within the required timeframe. Similarly, another resident with end stage kidney disease and diabetes mellitus had several low blood sugar readings, but documentation did not show that the physician was notified or that the hypoglycemic protocol was followed as ordered, including timely reassessment after intervention. Additionally, a resident with a history of stroke, coronary artery disease, heart failure, hypertension, diabetes mellitus, and high cholesterol had physician's orders for blood pressure checks twice daily. However, the medication administration record showed missing documentation for required blood pressure checks on several occasions. Interviews with the Director of Nursing confirmed that the required monitoring and notifications were not completed as ordered for these residents.