Failure to Reconcile Medications and Monitor Diabetic Resident Leads to Immediate Jeopardy
Penalty
Summary
Nursing staff failed to demonstrate competency in reconciling hospital discharge medication orders, monitoring blood glucose levels for a diabetic resident, and recognizing or responding to elevated blood pressures and abnormal laboratory results. Upon admission, the resident, who had a history of type 2 diabetes mellitus, hypertension, and nontraumatic intracerebral hemorrhage, was confused and unable to communicate her medication needs. Despite clear documentation in the hospital discharge instructions indicating the need for daily insulin and other specific medications, these orders were not properly entered into the facility's medical record. Instead, the resident received medications not listed on her hospital discharge summary, and some required medications, including insulin, were omitted entirely. Throughout the resident's stay, there was a lack of appropriate monitoring and response to critical health indicators. Blood glucose checks were not performed from admission until the day the resident was transferred to the hospital, despite the resident being diabetic and having abnormal lab results indicating hyperglycemia. The resident also experienced multiple episodes of significantly elevated blood pressure, with inconsistent or delayed provider notification and intervention. Laboratory results showing dangerously high blood glucose and other abnormal values were reviewed by nursing staff but not communicated to the provider in a timely manner, and there was no documentation of follow-up or corrective action. Interviews with staff revealed confusion and lack of clarity regarding the medication reconciliation process, with nurses relying on incomplete or incorrect documentation and failing to ensure provider review and verification of orders. Admission checklists and protocols were inconsistently used or not documented, and there was no reliable system to confirm that chart checks and medication reconciliations were completed accurately. The resident's condition deteriorated during her stay, culminating in a critical hyperglycemic episode that required emergency transfer to the hospital.