Falsification of Blood Sugar and Insulin Administration Documentation
Penalty
Summary
A deficiency occurred when the facility failed to maintain accurate medical records for a resident with multiple complex diagnoses, including Type 2 Diabetes Mellitus with chronic kidney disease, end stage renal disease, and atherosclerotic heart disease. The resident had physician orders for blood sugar checks and insulin administration according to a sliding scale. On the date in question, documentation in the Treatment Administration Record (TAR) reflected multiple blood sugar readings and insulin administrations, all showing the same elevated blood sugar value and corresponding insulin doses, signed by different nurses. However, it was discovered that one nurse did not actually perform the required blood sugar checks and instead used another nurse's earlier readings to document care that was not provided. This resulted in false entries in the resident's electronic health record, including documentation of blood sugar checks and insulin administration that did not occur as recorded. The resident was subsequently admitted to the hospital and diagnosed with diabetic ketoacidosis (DKA), a serious complication of diabetes. Interviews with facility staff and review of records confirmed that the nurse involved admitted to not performing the blood sugar checks and using another nurse's readings for documentation. The facility's leadership and other nursing staff acknowledged that such actions constitute falsification of documentation and are strictly prohibited, as accurate documentation is essential for resident care and safety.