Failure to Accurately Document Ordered Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to maintain an accurate medical record by not documenting physician-ordered blood glucose testing for a resident with Diabetes Mellitus. The resident’s current Physician Order Sheet dated August 2025 included an order for Insulin Lispro 100 Unit/mL to be administered per sliding scale based on blood glucose monitoring before each meal, with a current order for fingerstick blood glucose monitoring twice daily. Review of the resident’s Medication Administration Record for August 1–25, 2025 showed that staff did not document the resident’s fingerstick blood glucose results on multiple dates, specifically August 6, 8, 10, 15, 17, 20, 21, 22, 23, and 24, 2025. During an interview on August 27, 2025 at 8:40 A.M., the DON confirmed the physician’s order for twice-daily fingerstick blood glucose monitoring and stated that staff were expected to perform the testing and record the results in the medical record for the physician to monitor the resident’s blood sugar levels. This lack of documentation of ordered blood glucose testing for a resident with Diabetes Mellitus constituted a failure to maintain an accurate medical record in accordance with accepted professional standards.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.