Failure to Complete Ordered Lab Monitoring for Hypoglycemic Regimen
Penalty
Summary
Surveyors identified a deficiency related to failure to monitor the effectiveness of a resident’s hypoglycemic medication regimen. The resident had a diagnosis of diabetes mellitus, impaired judgment, and memory deficits, and required staff support. Her MDS documented that she received insulin injections and hypoglycemic medications, and her care plan noted altered endocrine status related to hyperglycemia and hypoglycemia due to diabetes mellitus. However, the care plan dated 02/23/26 did not include monitoring of laboratory tests for diabetes mellitus. Physician orders included multiple diabetes-related medications (Jardiance, glargine insulin, Januvia, and Humalog insulin) and also ordered a CBC, CMP, and HbA1c every six months. The EMR showed that an HbA1c was completed on 07/01/25, a CBC on 08/01/25, and a CMP on 01/02/26, but there was no evidence that the CBC and HbA1c ordered for 01/02/26 were completed. During interviews, Administrative Nurse E confirmed that the CBC and HbA1c were not completed and that the January medication administration record listed the CBC, CMP, and HbA1c without any documentation explaining why they were not done or rescheduled. Nurse E stated that physician orders were expected to be followed and explained that routine lab draws were performed weekly by an outside laboratory, with the charge nurse responsible for ensuring completion. The facility’s Drug Regimen Review policy indicated that a resident’s medication regimen would be reviewed monthly and as needed by a licensed pharmacist, using laboratory values as indicated, and that the pharmacist would have access to residents’ lab tests. Despite these requirements, the necessary laboratory monitoring for the resident’s diabetes management was not carried out or documented, resulting in a failure to ensure the resident’s drug regimen was monitored for effectiveness.
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