F0684

E

Failure to Monitor and Document Blood Glucose and Hypoglycemia per Physician Orders

Lancaster, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and professional standards of nursing practice for monitoring and documenting blood glucose and hypoglycemia in a resident with type 2 diabetes mellitus. The resident was admitted with diagnoses including type 2 diabetes, major depressive disorder, and essential hypertension, and had severely impaired cognitive skills for daily decision making per the MDS. Physician orders dated 4/7/2023 required licensed nurses to monitor the resident’s blood glucose every four hours, and orders dated 9/9/2025 required monitoring for signs and symptoms of hypoglycemia each shift, with documentation of the presence or absence of those signs and symptoms in the medical record. The resident’s care plans for hypoglycemic medications and type 2 diabetes directed staff to monitor blood sugar per physician orders and to monitor, document, and report signs and symptoms of hypoglycemia.

Record review showed that the resident’s blood sugar was not monitored and documented every four hours as ordered. The MAR for 12/1/2025 to 12/31/2025 contained no evidence that blood sugar checks were performed every four hours for 21 days. The Blood Sugar Summary for 12/1/2025 to 12/21/2025 showed blood sugar levels were taken and documented four times a day instead of every four hours (six times a day). During interview, the LVN confirmed that the documentation did not show every-four-hour monitoring and stated that care not documented was considered not provided. The DON also confirmed there was no documented evidence of blood sugar monitoring every four hours, and acknowledged that the facility failed to ensure the resident’s health status was monitored according to physician orders.

The deficiency also includes a failure to document the resident’s hypoglycemia and related signs and symptoms in the MAR during a documented change of condition. On 12/21/2025, an SBAR COC form documented that the resident was observed with labored breathing, altered level of consciousness, and a blood sugar level of 45 mg/dL at 4:50 a.m., and that the resident received intramuscular glucagon and oral glucose gel before transfer to an acute care hospital. However, the DON stated that the resident’s signs and symptoms of hypoglycemia during this change of condition were not documented in the MAR. Facility policies on diabetes care and documentation required monitoring for complications of diabetes, incorporation of physician-ordered blood glucose parameters into the MAR and care plan, identification and reporting of changes in condition such as hypoglycemia, and documentation of relevant findings in the clinical record, which were not followed in this case.