Failure to Implement Diabetes Monitoring Interventions
Penalty
Summary
The facility failed to implement care plan interventions for two residents with diabetes mellitus, specifically regarding the monitoring, documentation, and reporting of signs and symptoms of hypoglycemia and hyperglycemia. For both residents, the care plans included detailed interventions to monitor for symptoms such as sweating, tremor, increased heart rate, confusion, and other indicators of blood glucose fluctuations. Despite these documented interventions, medical record reviews revealed no evidence that the required monitoring was performed or documented for either resident during their stays. Interviews with nursing staff and the Director of Nursing confirmed that the monitoring for hypoglycemia and hyperglycemia was not conducted as outlined in the residents' care plans. Both residents were identified as being at high risk for blood sugar fluctuations due to their diagnoses of diabetes, with one also having diabetic chronic kidney disease. The lack of monitoring was acknowledged by staff, who stated that licensed nurses should have performed and documented these assessments as part of the residents' individualized care plans.