Failure to Maintain Current Diabetic Orders and Consistent Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s diabetic drug regimen and related monitoring were supported by current physician orders and appropriate blood glucose checks. A resident with type 2 diabetes, chronic pain, anxiety disorder, muscle weakness, and bilateral age-related nuclear cataracts was admitted on 12/24/25 and had intact cognition, required substantial assistance with mobility, and used an electric wheelchair. The care plan dated 02/03/26 identified the resident as insulin dependent, with interventions to administer diabetes medications as ordered and monitor side effects and effectiveness. The December 2025 and January 2026 MARs showed an order for Humalog KwikPen per sliding scale from 12/27/25 through 01/17/26 and an order for a Freestyle Libre continuous blood glucose monitoring device from 12/31/25 through 01/13/26, with no new orders entered after those end dates. From 01/19/26 through 02/02/26, blood glucose monitoring for this resident was sporadic and not performed consistently throughout the day, with some days having one or two checks and several days with no checks at all. The resident reported that staff were not checking blood glucose levels throughout the day. An LPN stated she checked the resident’s blood glucose without having an order and described the situation as confusing, with staff checking blood sugars randomly rather than on a scheduled basis, and indicated she would need to contact the physician for order verification. The physician later stated he was unaware there was no order to check blood sugars before meals and that it made no sense to check when there was a plan in place. The DON confirmed there was no new order for a sliding scale or for staff to check the resident’s blood glucose three times a day. Review of the facility’s undated Insulin Administration policy showed it provided little guidance on the frequency of blood glucose monitoring.
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