Failure to Follow Physician Orders for Diabetic Monitoring and A1c Lab
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own policy regarding diabetes management and lab monitoring for one resident. The resident had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, metabolic encephalopathy, bipolar disorder, schizoaffective disorder, chronic embolism and thrombosis of the femoral vein, and difficulty in walking, and was documented as having severe cognitive impairment with a BIMS score of 3/15. A physician order dated 2/19/2026 directed that an A1c lab be completed on 2/20/2026, with instructions that if the resident refused, a different technician should attempt the draw in the morning. Progress notes show the resident refused the A1c at 1:02 AM on 2/20/2026, but there is no documentation that the A1c was offered again by a different technician as ordered. The DON stated that if it is not documented, it is not done. The facility also failed to document blood glucose monitoring parameters for when to notify the physician, despite the DON stating that the physician gives such parameters and that nurses should carry out orders as written. The RN caring for the resident reported that the resident is diabetic and that blood sugars are taken two times a shift, but she could not locate the blood glucose levels she documented and did not know the parameters for when to notify the physician. Blood glucose records from 2/20/2026 to 2/27/2026 show levels ranging from 122 mg/dL to 230 mg/dL, and on 2/28/2026, blood glucose checks ordered for 8:00 AM and 11:00 AM were documented as taken at 2:03 PM, which did not align with the physician’s ordered times. These actions and omissions conflict with the facility’s policy requiring that all treatments and plans of care be in accordance with physician orders and that orders in the POS be accurately reflected in the MAR.
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