A note that documents only “WNL” or “no change” reads as observations any layperson could record, and gives a surveyor no evidence an assessment occurred. There is no defense to a denial because the note never claimed a licensed clinician was required — and never proved the need was daily.
Before — does not survive
Endo: WNL. No issues today.
After — survives
Skilled endocrine assessment this shift: capillary blood glucose 118 mg/dL, within the ordered parameter of 80–180; no hypo/hyperglycemia. Insulin administered per the ordered scale; sites clear, technique accurate. Feet intact; monofilament 10/10 bilaterally. Licensed assessment required to detect glycemic pattern shifts requiring provider-directed adjustment and to evaluate steroid-associated hyperglycemia from the pneumonia treatment; supports the Section N insulin day and Section I diagnosis and the care-plan glycemic goal. Daily skilled monitoring required at SNF level.
