Failure to Ensure Consistent Blood Sugar Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident with diabetes received blood sugar monitoring and insulin administration in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. Upon admission, the resident was prescribed 70/30 insulin twice daily, but there was no clear physician order for blood sugar monitoring. Nursing staff inconsistently monitored the resident's blood sugar without an order until one was entered two weeks after admission, following concerns raised by the resident's family. Documentation showed irregularities in the frequency and timing of blood sugar checks, with some days missing readings entirely and others not aligning with the expected schedule of monitoring before meals and at bedtime. Physician notes indicated that blood sugar monitoring should have occurred before meals and at bedtime, but no corresponding order was present until later. Interviews with nursing staff and the DON revealed uncertainty about the lack of a monitoring order and the inconsistent practice prior to the formal order being entered. The facility's policy required that insulin administration and blood glucose monitoring be performed per physician order and care plan, but this was not followed. The resident had diagnoses including diabetes, heart failure, and a recent ankle fracture and repair, and was cognitively intact at the time of the deficiency.