Failure to Verify Blood Glucose Readings for Visually Impaired Diabetic Resident
Penalty
Summary
The facility failed to ensure quality of care for a resident with type 1 diabetes mellitus and diabetic retinopathy by not following physician orders and care plan instructions regarding blood glucose monitoring. The resident's orders specified that blood sugar should be checked before meals and at bedtime using the facility's glucometer, with nursing staff required to observe and verify the reading. The care plan also noted the resident's impaired vision and required nursing staff to read the glucometer after the resident checked their own blood glucose. During observation, a nurse asked the resident for their blood sugar reading and accepted the resident's verbal report without directly observing the glucometer or the reading. Interviews with staff confirmed that the resident used their personal glucometer and that staff often relied on the resident's verbal report rather than verifying the reading themselves, despite the resident's visual impairment and the facility's instructions that staff must observe and verify the result using the facility's equipment.