Failure to Document Diabetes Management Plan After Elevated HgbA1C Result
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the medical provider documented an appropriate plan of care for a resident’s diabetes during required regulatory visits. The resident was admitted with a diagnosis of diabetes, and during a regulatory visit in late September, the nurse practitioner (NP) documented that the diabetes was diet controlled. A Hemoglobin A1C (HgbA1C) lab ordered in mid-October showed an elevated result of 8.1%, significantly above the lab’s normal range of ≤5.7%. The electronic lab record showed the NP signed off on these results in early November, but there was no corresponding provider progress note on that date addressing the elevated HgbA1C. Following the September visit, the next documented regulatory visit by the NP occurred in mid-December. In that progress note, the NP documented that the resident’s Type 2 diabetes with chronic kidney disease was diet controlled, referenced an older HgbA1C of 6.5% from the previous year, and planned to continue a healthy diet. The NP did not reference or address the more recent elevated HgbA1C of 8.1% from October in this regulatory visit note. During interview, the NP stated she had discussed with the resident the option of more frequent blood sugar checks and treatment, and that the resident preferred diet control with reevaluation in three months, but she acknowledged that she had not documented this discussion or the diabetic plan in the regulatory progress note, and confirmed she should have done so.
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