Failure to Document Blood Glucose Monitoring for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to document blood sugar levels in accordance with physician orders and accepted professional standards for two residents with diabetes. Resident #1, who had moderate cognitive impairment and a diagnosis of type 2 diabetes, had a physician’s order to obtain blood sugar levels prior to meals starting on 12/17/2024. Review of the December 2025 and January 2026 Electronic Medication Administration Records (eMAR) showed no documented evidence that blood sugar levels were obtained on specific early morning dates and times, despite the order. Resident #1 reported not having his blood sugar checked in the mornings as required. An LPN later stated she had obtained Resident #1’s blood sugar levels on the identified dates but failed to document the results in the eMAR, and the Director of Nursing confirmed the lack of documentation. Resident #2, admitted with a diagnosis of diabetes mellitus without complication, had a physician’s order for NovoLOG insulin per a sliding scale, with parameters based on blood sugar levels obtained before meals and at bedtime. Review of Resident #2’s December 2025 and January 2026 eMARs revealed missing documentation of blood sugar levels on several specified dates and times. One LPN reported obtaining Resident #2’s blood sugar level on an identified evening but not documenting it in the eMAR, while another LPN reported obtaining blood sugar levels on two identified mornings but also failing to document them as required. The Director of Nursing indicated that Resident #2’s blood sugar levels should have been documented in the eMAR on those dates.
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