Incomplete Medical Record Documentation for Diabetic Resident
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident with diabetes, as evidenced by several documentation lapses. The resident was admitted with a diagnosis including diabetes, and during a review of the medical record, it was found that on one occasion, staff documented a blood sugar reading of 401 but did not record the insulin administered. On another occasion, a blood sugar reading of 17 was documented without an accompanying nurse's note, and on a separate date, the blood sugar was not documented at all. These deficiencies were confirmed by the Director of Nursing during an interview, indicating that required documentation related to blood sugar monitoring and insulin administration was incomplete or missing for this resident.