Failure to Transcribe and Implement Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to follow physician orders for blood glucose monitoring for one resident with type 2 diabetes mellitus, morbid obesity, depressive disorder, panic disorder, and anxiety. The resident was admitted from another LTC facility with a discharging physician order dated 10/01/25 for blood sugar monitoring two times a day. The admission MDS showed the resident had intact cognition, required setup assistance for eating, toileting, bed mobility, and transfers, and received insulin injections during the assessment period. However, review of the admission physician orders dated 10/31/25 showed no order for blood sugar monitoring, and the active physician orders did not include blood glucose checks until an order for a daily fasting blood sugar was written on 12/04/25. On interview, the DON confirmed that the blood sugar monitoring order from the prior facility was not transcribed into the electronic health record at admission and acknowledged that it should have been. The DON also verified that no blood sugar checks were completed for this resident from admission until 12/04/25, when the daily fasting blood sugar order was entered. This failure to transcribe and implement blood glucose monitoring orders resulted in the resident not receiving ordered blood sugar checks during that period, as identified under Complaint Number 2662752.
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