Failure to Provide Timely Wound Care and Blood Sugar Monitoring
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility with multiple skin impairments, including a diabetic wound to the left heel and dorsum of the foot, moisture-associated skin damage (MASD) to the sacrum, and an abrasion to the penis. Upon readmission, the admitting nurse identified skin impairments but did not document their location or measurements on the required forms and failed to communicate these findings to the nurse practitioner (NP) or request wound care orders. As a result, the resident did not have any wound care orders in place for five days following readmission, and no wound care was provided during this period. The facility's policy required notification of the physician for any new treatment needs or changes in condition, but this was not followed. Additionally, the same resident, who had a history of type 2 diabetes mellitus and was on oral diabetic medications, was readmitted without orders for blood sugar checks. The admitting nurse verified the medication list with the NP but did not request or clarify the need for blood sugar monitoring, despite the resident's diagnosis and previous history of fluctuating blood sugars. For five days, no blood sugar checks were performed, and the resident subsequently experienced an episode of hypoglycemia, with a blood sugar reading of 50, which led to a hospital transfer. The lack of blood sugar monitoring was not addressed until after the incident occurred. Interviews with facility staff, including the admitting nurse, ADON, NP, and DON, revealed a lack of communication and understanding regarding the need to obtain and clarify orders for wound care and blood sugar checks upon admission. Documentation was incomplete, and staff did not follow facility policy or professional standards of practice in assessing, documenting, and reporting the resident's condition. The facility did not have a specific policy for diabetic procedures or blood sugar checks, and staff training on these procedures was lacking at the time of the incident.