Failure of Monthly Drug Regimen Review to Address Out-of-Range Blood Glucose Levels
Penalty
Summary
Surveyors identified a deficiency in the facility’s monthly drug regimen review process related to a resident with diabetes mellitus who received daily insulin and oral diabetes medications. The resident’s admission MDS documented intact cognition and confirmed a diagnosis of diabetes with daily insulin injections, and the care plan directed staff to monitor and document side effects and effectiveness of diabetes medications. An intervention added to the care plan instructed staff to check fasting blood sugars as ordered and to notify the provider for readings less than 60 mg/dl or greater than 350 mg/dl. Physician orders also required blood glucose monitoring twice daily with a directive to call the physician if levels were below 60 mg/dl or above 350 mg/dl. Record review of the resident’s EMR from July 2025 through February 2026 showed multiple blood glucose readings above 350 mg/dl, including values ranging from the mid-350s to as high as 596 mg/dl on numerous dates. The progress notes lacked documentation that the provider was notified of these out-of-range blood glucose levels as required by the physician’s order and care plan parameters. Additionally, review of the Drug Regimen Reviews from August 2025 to February 2026 showed no documentation that the consulting pharmacist identified these elevated blood sugars as being out of range or as a monitoring concern, despite facility policy stating the pharmacist will complete a monthly drug regimen review and identify medications without proper monitoring. An administrative nurse stated she expected the pharmacist to recognize when a medication was outside ordered parameters and notify the facility.
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