Failure to Provide Diabetic Care and Falsification of Documentation
Penalty
Summary
A facility failed to ensure that a resident with a history of Type 2 Diabetes Mellitus, diabetic chronic kidney disease, and end stage renal disease received treatment and care in accordance with professional standards of practice. On the date in question, the resident's blood sugar was found to be critically high (522 mg/dl) in the early morning. The physician was notified and provided orders for insulin administration and further monitoring. However, subsequent blood sugar checks and insulin administrations were documented by a nurse who did not actually perform the required blood glucose testing, instead using a previous reading obtained by another nurse. The nurse documented multiple blood sugar readings and insulin administrations throughout the day without performing the necessary assessments, thereby falsifying medical records. The resident, who was severely cognitively impaired and had a history of non-compliance with her diabetic regimen, began to feel unwell and requested to be taken to the hospital. Her family transported her to the emergency room, where she was diagnosed with diabetic ketoacidosis (DKA), a serious complication of diabetes. Interviews with the resident and her family indicated that the nurse did not check her blood sugar or administer insulin prior to her leaving the facility, despite documentation to the contrary. The falsification of records was later confirmed through interviews with facility staff and review of documentation practices. The incident was identified as past non-compliance, with the nurse admitting to using another nurse's earlier blood sugar reading for documentation and not performing the required care. The facility's investigation determined that the nurse failed to follow physician orders, did not check the resident's blood sugar as required, and falsified documentation regarding both blood sugar checks and insulin administration. This failure resulted in the resident not receiving necessary diabetic care and contributed to her hospitalization for DKA.