Missed Blood Sugar Check and Documentation for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with diabetes, who was alert, oriented, and able to make complex medical decisions, did not have their blood sugar checked as ordered before lunch on a specific day. The resident was on long-term insulin therapy and had physician orders for blood sugar monitoring four times daily (before meals and at bedtime). Documentation showed that the blood sugar was checked in the morning after breakfast, but there was no record of a blood sugar check or insulin coverage before lunch, nor was there documentation that the resident refused the check. The Director of Nursing confirmed that the expectation was for licensed nurses to follow physician orders and document all medication and treatment administration in the resident's clinical record. The facility's policy required that all medications and treatments be administered as prescribed and recorded on the appropriate administration record. The failure to check and document the resident's blood sugar before lunch represented a lapse in following physician orders and facility policy for diabetes management.