Failure to Monitor and Document Diabetic Care and Glucose Checks
Penalty
Summary
The facility failed to provide quality care and services for two residents by not ensuring proper monitoring and documentation related to diabetic management. For one resident with Type 2 diabetes and no decision-making capacity, the facility did not document monitoring for side effects or effectiveness of prescribed insulin, nor did they monitor or document for signs and symptoms of hyperglycemia as outlined in the resident's care plan. Both the RN and DON confirmed that there was no evidence of such monitoring or documentation in the medical record, and that clarification with the physician regarding blood sugar monitoring was not obtained. For another resident, the facility did not complete physician-ordered daily glucose monitoring on several specified dates, as evidenced by missing documentation in the medication administration records. The RN verified the omissions and acknowledged that reasons for missed glucose checks were not documented. The DON also confirmed these findings, stating that refusals or other reasons should have been recorded to ensure proper tracking of the resident's blood sugar status.