Failure to Transcribe and Implement Diabetes Management Orders for Respite Admission
Penalty
Summary
A deficiency occurred when a facility failed to accurately transcribe and implement physician orders for a resident admitted for respite care with a history of type 2 diabetes, dementia, hypertension, and chronic kidney disease. The resident's FL2 form, completed by the primary care provider, included orders for Metformin, Empagliflozin, Lantus insulin (5 units at bedtime), and continuous glucose monitoring. However, during the transcription of these orders into the electronic health record (EHR), the orders for Lantus and blood glucose monitoring were omitted. Multiple nurses involved in the admission and care process did not verify the FL2 orders against the EHR or the medications brought in by the responsible party, resulting in the resident not receiving Lantus or having blood glucose monitored during the entire stay. Staff interviews revealed that the nurse initially responsible for transcribing the orders was unsure why the Lantus and glucose monitoring orders were not entered. The admitting nurse relied on the previously transcribed orders and did not check the FL2 form for accuracy, nor did she verify the medication bag contents thoroughly. Subsequent nursing staff followed the medication administration record (MAR) and did not administer Lantus or perform blood glucose checks, as these were not listed in the EHR. None of the staff noticed or inquired about the resident's continuous glucose monitoring device, and no one contacted the provider for clarification regarding the missing orders or the absence of the monitoring device. As a result, the resident did not receive prescribed insulin or have blood glucose monitored during the respite stay. After discharge, the responsible party discovered the resident's blood glucose was critically high, administered Lantus, and contacted EMS. The resident was subsequently transferred to the emergency department with hyperglycemia, elevated heart rate, and diarrhea, and was treated with intravenous fluids. The omission of critical diabetes management orders directly led to the resident's acute medical episode following discharge.
Removal Plan
- Resident #1's case was investigated by the Director of Nursing (DON), including staff interviews, surveillance footage review, and chart audit to determine the omission of insulin and blood glucose monitoring orders.
- DON contacted Resident #1's Responsible Party (RP) to inform her of the investigation findings and provided education on signs and symptoms of hypo/hyperglycemia and when to call emergency services.
- DON audited all respite residents admitted, comparing FL2 forms and EHR orders to identify discrepancies.
- Discrepancies found in other residents were addressed by verifying home medications with the RP and notifying the provider for clarification and new orders.
- DON provided verbal education to all nurses regarding omission of admission orders for respite residents.
- Facility will continue to obtain an FL2 prior to offering respite admission.
- Admissions Director will continue to communicate with RPs that home medications are required upon arrival.
- All nurses instructed to use the FL2 to transcribe orders into the EHR and compare medication bottle labels with EHR orders upon admission.
- If discrepancies are found, the assigned nurse will contact the family to determine the current medication regimen and notify the provider for clarification.
- If the family cannot be reached, the nurse will contact the provider for clarification of orders.
- If medications are not provided by the RP upon admission, the nurse will contact the provider and obtain medications from the facility's contracted pharmacy.
- All newly hired nurses (facility, agency, contract) will receive verbal education on transcription of respite resident orders before training on the floor.
- DON or designated nursing supervisor will audit respite residents, physically observing home medications and ensuring accurate transcription of all orders.
- DON or designee will compare EHR orders to each resident's FL2 and home medications on the day of admission for each respite resident.
- Daily audits will be completed and reviewed at the next scheduled QAPI meeting.
- ADHOC QAPI review was completed by the DON.