Failure to Monitor and Document Blood Glucose and Oxygen Saturations per Physician Orders
Penalty
Summary
Facility staff failed to monitor and document a resident's blood glucose levels and oxygen saturations as ordered by the physician. The resident, who had diagnoses including ischemic cardiomyopathy, type 2 diabetes mellitus, and heart disease, was admitted and discharged within a short period. Physician orders specified the administration of insulin and Trulicity for diabetes management, as well as blood glucose monitoring four times daily with instructions to notify the physician if readings were below 60 mg/dL or above 400 mg/dL. However, review of the medication and treatment administration records for the relevant month showed no documentation that blood glucose monitoring was performed as ordered during the resident's stay. During an interview, the regional nurse confirmed that the resident was using a Free Style blood glucose monitoring system, which recorded readings on the resident's personal phone. Despite this, the readings were not recorded in the resident's medical record by facility staff. The lack of documentation and monitoring as per physician orders was confirmed by the regional nurse, constituting a failure to provide appropriate treatment and care according to orders and the resident's needs.