Lakes of Monclova: Insulin Documentation Failures - OH
Licensed Practical Nurse #201 administered 10 units of insulin to Resident #13 at 12:37 A.M. on August 14, following a physician's order for hyperglycemia. The nurse checked the resident's blood sugar an hour later and found it was 254 mg/dL, still dangerously elevated. But she never entered that crucial reading into the electronic medical record.
The documentation failure meant that when the Director of Nursing reviewed the resident's progress notes the next morning, she only saw part of the story. The DON read about the 12:37 A.M. insulin dose but had no idea that Resident #13 had actually received 30 units of insulin total for hyperglycemia during the overnight shift from August 13 to August 14.
During an interview on September 8, LPN #201 confirmed she had worked the midnight shift from 12:00 A.M. until 6:00 A.M. and provided care for Resident #13. She recalled checking his blood sugar after giving the insulin and remembered the 254 mg/dL result. But when investigators asked about documentation, she admitted she had failed to record the reading.
The missing documentation created a cascade of communication failures. The DON told investigators she became aware of Resident #13's hyperglycemic episode only by reading his progress notes after the fact. Without the complete picture of his overnight insulin treatments and blood sugar responses, she couldn't fully assess his condition or coordinate appropriate follow-up care.
Facility policy requires that every entry to the medical record include the date, time, and signature of the staff member recording the data. The policy, last reviewed in December 2024, emphasizes that staff should make "every effort" to record information or events as soon as they occur.
For diabetic residents like Resident #13, accurate blood sugar documentation is critical for safe care. Blood glucose readings guide insulin dosing decisions and help medical staff identify patterns that could signal the need for treatment adjustments. When readings go undocumented, the next shift of nurses lacks essential information about how a resident responded to previous treatments.
The facility's telephone order policy also came into focus during the investigation. The policy requires that campuses with electronic medical records enter orders directly into the electronic system, which automatically transmits to the pharmacy. Telephone orders must be countersigned by the physician within 14 days of receiving the verbal order.
LPN #201's failure to document the blood sugar reading violated basic medical record-keeping standards. In facilities caring for diabetic residents, blood glucose monitoring creates a paper trail that allows medical staff to track treatment effectiveness and spot dangerous trends. Missing readings can mask episodes of severe hyperglycemia or hypoglycemia that require immediate intervention.
The documentation gap also meant that pharmacy staff reviewing Resident #13's medication administration records would lack complete information about his insulin response. This could affect future dosing recommendations and medication timing decisions.
Federal investigators classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But the incident highlighted broader concerns about medication administration documentation at the facility.
The investigation stemmed from a complaint filed with state authorities, assigned complaint number 2597107. Inspectors found that the facility's own policies clearly outlined expectations for timely, accurate medical record documentation, making the nurse's failure to document the blood sugar reading a clear policy violation.
For Resident #13, the missing documentation meant his medical record contained an incomplete picture of a potentially serious hyperglycemic episode. While he received the insulin treatment he needed, the lack of follow-up blood sugar documentation left gaps in his care record that could affect future treatment decisions.
The incident underscored how seemingly small documentation failures can create significant patient safety risks in nursing home settings, where accurate medical records are essential for coordinating care across multiple shifts and healthcare providers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakes of Monclova Health Campus The from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LAKES OF MONCLOVA HEALTH CAMPUS THE in MAUMEE, OH was cited for violations during a health inspection on September 8, 2025.
Licensed Practical Nurse #201 administered 10 units of insulin to Resident #13 at 12:37 A.M.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.