Failure to Obtain Admission Orders for Blood Sugar Checks and Wound Care
Penalty
Summary
A deficiency occurred when a resident with a history of type 2 diabetes mellitus, chronic heart failure, and multiple skin impairments was readmitted to the facility without physician orders for immediate care, specifically for blood sugar checks and wound care. Upon readmission, the resident did not have orders in place for blood glucose monitoring, despite being prescribed oral diabetic medications. The lack of blood sugar checks persisted for five days, during which the resident experienced a hypoglycemic episode with a blood sugar reading of 50, requiring transfer to the hospital. Interviews with facility staff revealed that the admitting nurse did not request or clarify orders for blood sugar checks, relying solely on the hospital medication list, and was unaware of the facility's policy or standard practice for diabetic care. Additionally, the resident was admitted with multiple skin impairments, including wounds to the left foot, left heel, sacrum, and penis, but did not receive wound care orders until four days after admission. The admitting nurse documented the presence of skin impairments but did not communicate these findings to the nurse practitioner or request treatment orders. The initial nursing evaluation indicated skin issues, but no detailed assessment or wound care plan was initiated until several days later. Staff interviews confirmed that the nurse did not follow the expected process of notifying the physician about new or existing wounds upon admission. The facility lacked a clear policy for diabetic procedures or wound care at the time of the incident, and staff training on these topics was inconsistent. The failure to obtain and implement physician orders for both blood sugar monitoring and wound care at the time of admission resulted in the resident not receiving necessary care for identified health needs. This deficiency was identified as Immediate Jeopardy due to the potential for significant harm.