Failure to Check Blood Glucose Prior to Administering Hypoglycemic Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with a physician’s order for monitoring blood glucose prior to administering hypoglycemic medications. A resident with diagnoses including Diabetes Mellitus, muscle weakness, and malignant neoplasm of the large intestine and rectum was admitted on 2/6/2026. The resident’s MDS dated 2/13/2026 documented moderately impaired cognition and the need for varying levels of assistance with activities of daily living. Telephone/verbal orders dated 2/7/2026 directed that the resident receive Glipizide 2.5 mg and Metformin 500 mg twice daily with meals, with fasting blood sugar checks ordered before breakfast at 6:30 AM and at bedtime at 9:00 PM, and instructions to call the physician if blood sugar was less than 70 or greater than 400. The resident’s care plan for diabetes, dated 2/7/2026, indicated the resident would be free from signs and symptoms of hypoglycemia. Review of the Medication Administration Record for 2/7/2026 showed that the fasting blood sugar ordered for 6:30 AM was not documented as completed prior to medication administration, and the DON confirmed that if it was not marked on the MAR, it was not done. The MAR further showed that the resident received Metformin 500 mg twice daily with meals and Glipizide 2.5 mg at 9:00 AM on 2/7/2026 without a recorded blood glucose check beforehand. The DON stated that the blood sugar should have been checked in the morning prior to medication administration as ordered and explained that when the order was entered, it was timed to begin at 9:00 PM and not before breakfast. The facility’s medication administration policy, revised 6/26/2025, stated that when medication administration is dependent on vital signs or testing, such as point-of-care blood glucose, the testing must be completed and recorded prior to administration, which did not occur in this instance.
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