Incomplete Documentation of Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that the medical record for a resident with type 1 diabetes was complete and accurate regarding blood glucose (BS) monitoring. The resident had multiple physician orders for frequent BS checks and insulin administration, including the use of both fingerstick (accucheck) and a continuous glucose monitoring device (Dexcom G7). Despite these orders, there was a lack of consistent documentation of BS readings in the medical record, including the Medication Administration Record (MAR), progress notes, and vitals log. On numerous occasions, BS values were either missing, not recorded as numerical values, or only noted as 'high' or 'low' without further detail. There were also instances where the resident refused BS checks or insulin, but the attempts and outcomes were not always fully documented. Interviews with nursing staff and the DON revealed that the facility did not have a specific policy for BS monitoring and relied on physician orders to guide practice. Staff reported that BS values should be recorded on the MAR, but review of the MAR for the relevant months showed no such documentation. Staff also indicated that the process for ensuring BS monitoring orders were properly reflected in the MAR was not always followed, as the nurse practitioner entering the order did not select the necessary options to trigger MAR documentation. Additionally, there was confusion among staff regarding the interpretation of the Dexcom device readings and when to notify providers of abnormal results. The resident involved had a complex medical history, including type 1 diabetes, cerebral infarction, and dementia, and required close monitoring of blood glucose levels. The care plan did not include specific interventions for BS monitoring with either the accucheck or Dexcom device. Throughout the period reviewed, there were multiple days with missing or incomplete BS documentation, and on several occasions, there was no evidence that providers were notified of abnormal BS readings or that appropriate follow-up occurred. The lack of complete and accurate documentation could result in an incomplete medical record for the resident.