Incomplete Documentation of Insulin Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure the completeness and accuracy of a resident's medical record in relation to the management of elevated blood sugars. A resident with type one diabetes mellitus experienced multiple episodes of hyperglycemia, during which three separate doses of Novolog insulin were administered in response to high blood sugar readings. Although the on-call practitioner provided verbal orders for these insulin doses, the nurse did not enter these orders into the resident's physician orders in the electronic medical record. Additionally, a follow-up blood sugar check, as ordered by the physician, was performed but not documented in the medical record. Interviews with the Director of Nursing (DON) and the LPN involved confirmed that the insulin administrations and the follow-up blood sugar result were not properly recorded according to facility policy. The DON also acknowledged that the interdisciplinary team was not fully aware of the extent of insulin administered overnight due to incomplete documentation. Review of facility policies indicated that all entries, including telephone orders, should be promptly and accurately recorded in the electronic medical record, but this was not done in this case.