Failure to Obtain Ordered A1C Monitoring for Diabetic Resident
Penalty
Summary
A resident with a diagnosis of diabetes mellitus had a physician’s order for Lantus Solostar insulin, 5 units in the morning and 27 units in the afternoon, and a standing laboratory order for hemoglobin A1C testing every February, May, August, and November to monitor average blood glucose levels. Facility policy required that laboratory services be provided or obtained when ordered by a physician or other authorized practitioner. During record review, surveyors requested the resident’s A1C results and the administrator reported that, after searching the record, there were no A1C results for February 2025. The ADON confirmed that A1C results were present for all ordered months except February 2025. The ADON stated they had spoken with the contracted dialysis company that month and believed the dialysis staff would perform the A1C test, and therefore the facility did not collect the blood sample for testing. As a result, the ordered A1C test for February 2025 was not obtained, and the resident’s A1C was not tested again until May 2025, contrary to the physician’s lab order and the facility’s laboratory services policy.
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