Failure to Accurately Document Blood Sugar Assessments and Insulin Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents with type 2 diabetes who required regular blood sugar (BS) monitoring and insulin administration. For both residents, the Medication Administration Record (MAR) did not contain documentation of the 8:00 PM BS check and insulin injection on a specific date, despite physician orders and care plans requiring these interventions. One resident had severe cognitive impairment and the other was cognitively intact, but both had orders for sliding scale insulin and BS monitoring before meals and at bedtime. During interviews, the LVN responsible for the residents' care on the date in question confirmed that she performed the BS checks and administered insulin as ordered, but failed to document these actions in the MAR. She stated that due to her PRN status and the hectic nature of her shifts, she sometimes wrote information on paper and charted later, which led to the omission. The DON confirmed that facility policy requires charting to be completed immediately after tasks or assessments are performed, or soon afterwards to prevent omissions.