Failure to Accurately Transcribe and Implement Blood Sugar Monitoring Orders
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic nephropathy was admitted with a physician's order to have blood sugar checked four times daily. The resident's care plan also indicated the need for regular blood glucose monitoring as ordered. However, record review showed that blood sugar checks were not performed as ordered, with documentation missing for 137 out of 152 opportunities during the review period. Further investigation revealed that the order for blood sugar monitoring was incorrectly transcribed into the electronic medical record (EMR) as an ancillary order rather than a treatment. As a result, the order did not populate on the resident's Treatment Administration Record, and nursing staff were unaware of the requirement to monitor the resident's blood sugar as prescribed. Both the registered nurse and the Director of Nursing Services confirmed the transcription error and the resulting lack of monitoring.