Failure to Review and Implement Blood Glucose Monitoring Orders After Hospital Discharge
Penalty
Summary
Facility staff failed to ensure that a resident's total program of care was reviewed following a hospital discharge, specifically neglecting to implement blood glucose monitoring orders for a resident with a diagnosis of diabetes. The resident's hospital discharge summary included instructions to continue using insulin, a blood glucose meter, and related supplies, but these orders were not transcribed into the clinical record upon admission. The clinical record lacked any provider orders for blood glucose checks, and the resident did not receive blood glucose monitoring until several days after admission, when the omission was identified and addressed. Interviews with facility staff revealed that the admitting nurse recalled seeing information about a dexcom device but did not recall further details, and the unit manager could not confirm whether the provider had reviewed the discharge summary at the time of admission. The provider was not on site during the admission, and there was uncertainty about who approved the resident's orders. The resident confirmed that blood glucose checks were not performed until after the issue was identified. The facility's policy required verification of transfer orders with the attending physician for immediate care, but this process was not followed in this instance.