F0842

D

Failure to Maintain Complete Insulin and Blood Glucose Monitoring Documentation

Lake City, Florida Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records and to document required notifications related to insulin administration and blood glucose monitoring for one resident with diabetes mellitus. The resident had physician orders for HumaLOG KwikPen insulin on a sliding scale before meals and at bedtime, and for Lantus SoloStar insulin at bedtime. Review of the MAR for November 1–30, 2025, showed multiple entries where blood sugar values were recorded as “NA” or left blank at ordered times (0630, 1130, 1630, and 2100), and one entry marked with an “X,” resulting in 16 occurrences where the resident’s blood sugar was not monitored as ordered to determine if sliding-scale insulin was required. The medical record for that period did not contain documentation that the physician was notified when the medication was not administered due to resident refusal and/or staff not performing the ordered blood sugar checks.

For the same resident, the MAR for November 1–30, 2025, documented Lantus SoloStar 100 UNIT/ML at bedtime with four doses marked with the chart code “2,” indicating drug refusal, on specific dates in November. The resident’s medical record did not contain documentation that the physician was notified of these refusals. In the subsequent period, December 1–20, 2025, the Lantus SoloStar order was changed to 25 units at bedtime, and the MAR documented five additional doses with the code “2” for refusal. Again, the medical record for this period did not show documentation that the physician was notified of the resident’s repeated refusals of the ordered insulin.

During the same December period, the MAR for HumaLOG KwikPen continued to show missing or incomplete documentation of blood sugar monitoring. At ordered times, multiple entries were documented as “NA” or with an “X,” resulting in 15 occurrences where the resident’s blood sugar was not monitored to determine if insulin administration was required. Interviews with the APRN and an LPN indicated that the resident frequently refused blood sugar checks and insulin, and that staff usually called the provider, but the LPN acknowledged there were times these calls were not documented. The DON stated that the facility’s expectation is that nurses notify family and the provider and document when a resident refuses medications or treatments. Facility policies on Physician Services and Medication Administration require that all physician orders be followed, reasons for not following orders be recorded in the medical record during that shift, and that refusals be reported and documented, which was not consistently done for this resident.