Failure to Monitor Blood Sugar and Perform Post-Fall Neuro Checks
Penalty
Summary
Facility staff failed to provide care and services to promote the highest level of wellbeing for three residents by not following physician orders and facility policies. For one resident with diabetes, acute/chronic respiratory failure, and a tracheostomy, staff did not perform or document blood sugar checks as ordered before meals and at bedtime on multiple occasions. The resident was cognitively intact and dependent for most activities of daily living. Staff interviews confirmed that if blood sugar checks are not documented, there is no evidence they were performed, and review of the facility's policy indicated that a physician's order must be verified for such procedures. Two other residents, both with significant medical histories including cerebrovascular accident, atrial fibrillation, NSTEMI, diabetes, CHF, subdural hemorrhage, and tracheostomy, experienced falls resulting in head injuries and bleeding. In both cases, the facility failed to initiate and document neurological checks post-fall as required by facility policy and standard clinical practice. Staff interviews revealed that neuro checks should be started immediately after a fall, especially when the resident is on anticoagulants or has sustained a head injury, and should be documented on a paper flowsheet. However, administrative staff confirmed that there was no evidence of neuro checks being performed for either resident after their respective falls. Facility documentation and staff interviews consistently indicated that the required monitoring and documentation were not completed for these residents. The facility's own policies on obtaining fingerstick glucose levels and managing falls and fall risks were not followed, and there was no evidence provided to show that the necessary assessments and interventions were carried out as ordered or per policy.