Failure to Assess and Document Change in Condition for Diabetic Resident
Penalty
Summary
A resident with multiple diagnoses, including COPD, dementia, atrial fibrillation, heart failure, and diabetes, experienced increased lethargy while admitted to the facility. On the day of the incident, a nurse documented the resident's lethargy and attributed it to a urinary tract infection for which the resident was being treated. However, the nurse did not document any vital signs, blood sugar checks, or a complete head-to-toe assessment at that time. The resident was subsequently sent to the hospital via 911, but the transfer assessment only included vital signs from the previous day, and there was no documentation of a current blood sugar measurement or comprehensive assessment. Interviews with staff revealed uncertainty about whether vital signs or blood sugar were checked at the time of the change in condition, with the last documented blood sugar recorded several days prior. The facility's policy requires appropriate assessment and documentation when a resident experiences a change in condition, but this was not followed. The Director of Nursing confirmed that lethargy in a diabetic resident should prompt a blood sugar check and a thorough assessment, neither of which were documented in the resident's electronic health record.