Failure to Document and Calibrate Glucometers per Protocol
Penalty
Summary
The facility failed to ensure that blood glucose meters (glucometers) were calibrated and that calibration was documented according to facility protocol and professional standards of practice on multiple occasions. Quality Assurance Logs for several medication carts across three stations showed missing documentation for multiple dates, with blank entries for critical information such as time, staff performing the check, machine lot number, test strip lot number, low and high control results, and actions taken. Interviews with nursing staff, including LVNs, an RN Supervisor, the Director of Staff Development, and the Director of Nursing, confirmed that the night shift was responsible for performing and documenting glucometer calibration, and that the day shift was expected to review and complete any missing documentation. However, there were acknowledged gaps in the logs, and staff confirmed that if documentation was missing, there was no way to verify if the glucometer checks were performed or if the readings were accurate. A review of facility policies indicated that staff were required to follow manufacturer instructions for glucometer use, including quality control monitoring, and to document all relevant information in the resident's medical record. Despite these policies, the logs for multiple medication carts in November were incomplete, with several days lacking any record of calibration or quality control checks. The Director of Nursing and other staff acknowledged that these omissions meant there was no assurance that glucometer readings for residents requiring blood glucose monitoring were accurate.