Failure to Obtain Diabetic Monitoring Orders for a Resident on Oral Hypoglycemics
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain and implement physician orders for hemoglobin A1C monitoring every 6 months and blood glucose capillary/fingerstick assessments at least twice weekly for one resident with type 2 diabetes. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and malnutrition and was prescribed oral sitagliptin. The resident’s MDS dated 2/14/25 documented severe cognitive impairment with a BIMS score of 6/15. Review of the admission record and the Order Listing Report showed no physician orders for A1C monitoring or blood glucose testing at admission or thereafter, despite the facility’s Diabetes Clinical Protocol requiring the provider to order glucose targets and monitoring regimens, including A1C on admission and every 6 months and at least twice-weekly blood glucose monitoring for residents on oral diabetic medications who are well controlled. The DON confirmed during interview that a physician’s order is required to perform blood glucose capillary/fingerstick testing and acknowledged that the resident had no such orders, even though it was important to assess blood glucose to determine blood sugar status and monitor the treatment plan. The attending MD stated that residents with stable type 2 diabetes on oral medications should have an order set in the EHR for A1C monitoring every 6 months and that this was a standard order set automatically placed on admission, but the resident did not receive it for reasons the MD could not explain. Medical Records and the Administrator reported that the MD had access to the facility EHR but used a personal EHR system, with relevant documents uploaded monthly by Medical Records. Review of the resident’s Weights and Vitals Summary showed no blood sugar assessments between admission on 3/11/24 and 3/18/25. The resident was later admitted to a general acute care hospital with altered mental status, including lethargy, confusion, partial responsiveness, and weakness, where labs showed a blood glucose level greater than 800 mg/dL.
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