Incomplete Documentation of Blood Glucose Monitoring and Activity Participation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for multiple residents. For one resident with type 2 diabetes mellitus without complications, a physician’s order dated 03/11/25 directed blood glucose monitoring twice monthly on the first and fifteenth. Review of this resident’s Treatment Administration Record (TAR) showed that blood sugar levels were not documented for the months of September, October, or November 2025. In an interview, the Regional Clinical Nurse confirmed that the blood glucose checks were not being documented in the medical record and acknowledged that blood glucose levels should be recorded at the time they are checked. The deficiency also includes failures in documenting and care planning for activity participation. One resident’s MDS indicated that being around animals, going outside in good weather, and participating in religious services were very important, and the care plan noted a preference for staying in her room watching TV and engaging in 1:1 activities. However, progress notes from late August through mid-November 2025 showed no documentation of group activity participation and only one entry of 1:1 activity. Another resident with unspecified dementia and behavioral disturbance had an activities assessment indicating that being around animals, keeping up with the news, group activities, going outdoors, and morning/afternoon activities were very important, but these preferences were not reflected in the care plan approaches/tasks. Additionally, this resident’s Activity Participation Record contained no documentation for September or October 2025, and the Activities Director confirmed that the resident was involved in daily activities and 1:1 programs but that daily participation and progress notes were not documented, and the care plan had not been updated for a year.
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