Failure to Routinely Monitor Hemoglobin A1C in Diabetic Resident
Penalty
Summary
A resident with a diagnosis of Type 2 diabetes was not routinely monitored for hemoglobin A1C levels over a 17-month period, despite care plan interventions directing monitoring of lab work as ordered by the physician. The resident was not receiving insulin or oral antidiabetic medications and was not on routine finger stick monitoring. Laboratory records showed periodic metabolic panels with glucose levels, but no hemoglobin A1C testing was documented during the review period. Interviews with clinical staff, including the APRN, attending physician, and Director of Nursing, confirmed that hemoglobin A1C testing should have been performed within the past year, but none could provide evidence that it was completed. The facility also lacked a policy for managing diabetic residents. The deficiency was identified after the resident experienced a fall during a transfer with a mechanical lift performed by a single nurse aide, contrary to safe transfer protocols. Following the fall, the resident was sent to the hospital, where an incidental finding revealed a critically elevated blood glucose level, leading to a diagnosis of hyperosmolar hyperglycemic state and ICU admission. The absence of routine hemoglobin A1C monitoring contributed to the lack of awareness of the resident's deteriorating glycemic control.