Failure to Monitor and Respond to Ordered Fasting Blood Glucose Checks
Penalty
Summary
The deficiency involves the facility’s failure to provide care and treatment in accordance with professional standards of practice for a resident with Type 2 diabetes mellitus, osteomyelitis, a non-pressure chronic ulcer of the left heel and midfoot, and cellulitis of the left lower limb. The resident was admitted with these diagnoses, and on 12/24/25 the physician ordered fasting blood sugar (FSBS) checks before breakfast with instructions to notify the physician for blood glucose (BG) results greater than 200 mg/dl. A physician progress note dated 12/30/25 directed that blood glucose levels be monitored closely to support wound healing. The resident’s care plan, dated 12/31/25, included a focus on nausea and vomiting with a goal for better control of blood glucose in 14 days, but there were no interventions documented to address how this goal would be met. Review of the Medication Administration Records (MARs) for 12/1/25 through 12/31/25 and 1/1/26 through 1/31/26 showed that FSBS tests before breakfast were not completed on multiple days after the order was initiated. Specifically, there were no FSBS tests documented before breakfast on 12/24/25, 12/25/25, 12/27/25, 12/29/25, 12/30/25, and 12/31/25, and no FSBS tests documented before breakfast on 1/1/26, 1/2/26, 1/3/26, 1/5/26, and 1/6/26. A blood glucose result of 256 mg/dl was documented on 1/6/26 at 8:30 AM. The facility’s policy on obtaining a fingerstick glucose level required the nurse to record blood sugar results in the medical record and promptly report results outside physician-ordered parameters to the supervisor and physician. During interviews and concurrent record reviews, a licensed nurse confirmed that the resident had an order starting 12/24/25 for FSBS checks before breakfast with instructions to report BG results greater than 200 mg/dl to the physician, and acknowledged that the ordered blood sugar checks were not completed for 11 out of 13 days between 12/24/25 and 1/6/26. The DON confirmed that breakfast trays were delivered between 7:00 AM and 8:00 AM, verified the missing FSBS tests for 11 of 13 days in that period, and confirmed that the elevated BG result of 256 mg/dl on 1/6/26 was not reported to the physician and no treatment for hyperglycemia was administered. The facility’s acute condition changes protocol required staff to monitor and document the resident’s progress and response to treatment so the physician could adjust treatment, but this monitoring and follow-up were not carried out as ordered for the resident’s blood glucose management.
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