Failure to Review and Address Diabetic Medication Changes Post-Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident's attending physician reviewed the hospital discharge summary following a hospital stay, specifically neglecting to address changes in the resident's diabetic medications. The discharge summary indicated that several diabetic medications, including insulin and metformin, were to be discontinued. However, upon the resident's readmission, there was no documentation of a medical provider reviewing or addressing these medication changes, nor were there new provider orders or progress notes explaining the discontinuation or providing alternative diabetic management. The resident had a complex medical history, including Type 2 Diabetes Mellitus with chronic kidney disease, atrial fibrillation, morbid obesity, and other significant comorbidities. Despite a care plan goal to prevent complications related to diabetes, the clinical record showed no evidence of diabetic medication orders or blood glucose monitoring after the resident's return from the hospital. The last recorded blood sugar check was prior to the hospital transfer, and subsequent lab results revealed persistently high glucose levels and an elevated A1C, indicating poor glycemic control. Interviews with administrative staff confirmed the absence of provider documentation or orders regarding the resident's diabetes management after readmission. The facility's policy required verification of transfer orders and provider review, but this process was not followed. The resident was unaware of his current diabetic medication regimen, and staff could not provide an explanation for the lack of diabetic care orders until the issue was identified during the survey.