Failure to Document and Perform Ordered Blood Sugar Checks for Diabetic Resident
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of drugs for a resident with multiple complex diagnoses, including end stage renal disease, heart disease, heart failure, and type 2 diabetes mellitus with hyperglycemia. The resident was admitted with orders for NovoLOG insulin to be administered according to a sliding scale, with blood sugar (BS) checks required four times daily. Record review revealed that on six separate occasions within a specified period, the resident's BS was not checked as ordered, and there was no documentation indicating that the procedure was attempted or any reason for omission. Interviews with an LPN, the DON, and the Administrator confirmed that all BS checks and medication administrations should be documented in the medical record, and that blank entries on the Medication Administration Record (MAR) indicated the procedure was not performed. The facility's policy required detailed documentation for each BS check, including the result, the person performing the procedure, and any reasons for not completing it. The DON was unable to locate any alternative documentation for the missing BS checks, and all staff interviewed acknowledged the importance of following physician orders and documenting all procedures as required.