Failure to Implement Blood Glucose Monitoring Orders for Diabetic Resident
Penalty
Summary
A resident with a diagnosis of type 2 diabetes mellitus and hyperglycemia was admitted to the facility and later sent to the hospital following a fall. Upon discharge from the hospital and return to the facility, the resident's convalescent care orders included instructions for blood glucose checks (accuchecks) before meals and at bedtime. The facility provider also documented the need to continue these blood sugar checks in the resident's progress notes. Despite these clear orders, a review of the resident's physician's orders revealed that no order for accuchecks or blood sugar checks was entered upon the resident's return from the hospital. Additionally, documentation showed that no blood glucose checks were completed by staff after a specific date prior to the resident's readmission. During an interview, the provider confirmed the intent for blood glucose monitoring and was unaware that the order had not been implemented.