Incomplete Documentation of Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for four residents with diabetes who required blood glucose monitoring and insulin administration. Specifically, the Medication Administration Records (MARs) and related documentation for these residents were found to be incomplete, with multiple instances where nurses did not initial or record insulin administration, blood glucose monitoring results, or meal announcements as ordered. These omissions were identified across several dates and affected both residents using insulin pumps and those receiving insulin injections. For example, one resident with type 1 and type 2 diabetes and an insulin pump had missing nurse initials for insulin administration, meal announcements, and blood glucose checks on several occasions. Another resident with similar diagnoses had missing documentation for both insulin and Ozempic administration, as well as for meal announcements and blood sugar checks. Two additional residents with type 2 diabetes, one of whom also had chronic kidney disease, had incomplete records for insulin injections, sliding scale insulin coverage, and fasting blood glucose checks. In several cases, the amount of insulin administered and the corresponding blood sugar levels were not documented as required. Interviews with staff revealed inconsistencies in the documentation process and uncertainty about whether medications and monitoring were performed as ordered. The DON acknowledged that there was no way to confirm if insulin was administered when documentation was missing. Staff interviews also indicated that the responsibility for blood glucose checks and insulin administration sometimes shifted between night and day shift nurses, and that documentation was not always completed in the electronic MAR. The facility's policy required detailed documentation of insulin administration and blood glucose monitoring, but this was not consistently followed for the residents reviewed.