Failure to Follow Physician's Order for Blood Glucose Monitoring
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes mellitus and diabetic nephropathy was admitted to the facility with an active physician's order to have blood sugar checked four times daily. Record review showed that this order, which was also reflected in the resident's care plan, was not followed. Specifically, between the admission date and the date of the survey, there was no evidence that the resident's blood sugar was checked as ordered, with 137 out of 152 opportunities missed according to the electronic medical record (EMR). During interviews, a registered nurse confirmed that blood sugar checks would be documented in the EMR and acknowledged being unaware of the physician's order. The Director of Nursing Services was unable to provide evidence that the order had been followed, and the nurse practitioner stated it was her expectation that the physician's order would have been carried out. No documentation was found to support that the required blood glucose monitoring was performed as directed.