Failure to Transcribe Physician Order for Blood Sugar Monitoring
Penalty
Summary
A deficiency occurred when a verbal physician's order for twice daily blood sugar checks was not correctly transcribed into the electronic medical record for a resident admitted with diagnoses including sepsis, diabetes mellitus, failure to thrive, and end stage renal disease requiring hemodialysis. The order, given by the Medical Director, was entered by a nurse who failed to select the appropriate option in the electronic system, resulting in the order not appearing on either the Medication Administration Record or the Treatment Administration Record. As a result, no blood sugar checks were performed during the resident's stay. The resident's care plan identified diabetes mellitus and the risk for related complications, with interventions to monitor for signs and symptoms of hyperglycemia and hypoglycemia. Despite this, a review of the electronic medical record showed no documentation of blood sugar monitoring from admission to discharge. Interviews with facility staff, including the DON and the nurse who entered the order, confirmed the transcription error and lack of blood sugar checks. The Medical Director confirmed the order was given due to the resident's history of low blood sugar episodes prior to admission.