Failure to Obtain Specialist Consultation and Administer Insulin as Ordered
Penalty
Summary
The facility failed to obtain a consultation with a specialist and administer insulin medications as ordered by the physician for two residents. Resident R40, who has a medical history of multiple sclerosis, paraplegia, lymphedema, and muscle weakness, expressed a preference for seeing a lymphedema specialist over the past seven months. Despite an active physician order for a lymphedema therapy consult dated August 31, 2024, there was no documented evidence of follow-up or appointment scheduling. A physician note from January 23, 2025, indicated that Resident R40 was refusing diuretics and ace wrapping, and expressed frustration that no action was being taken regarding her condition. The unit clerk, Employee E9, attempted to locate a treatment center but was unsuccessful, and no further action was documented. Resident R94, with a medical history of chronic kidney disease and type 2 diabetes mellitus with diabetic neuropathy, had a physician order for insulin Aspart to be administered before meals at 11:00 a.m. However, a facility audit revealed that the insulin was administered at 2:04 p.m. on February 2, 2025, by a licensed nurse, Employee E10, which did not align with the physician's order. This failure to administer medication as prescribed could potentially impact the resident's health and well-being.
Plan Of Correction
Resident R40 has lymphedema assessment pending by facility lymphedema specialist. Resident 94 had no ill effects from insulin administration. Resident charts audited for outpatient specialty orders for the past 14 days to ensure appointments are scheduled. All residents have the potential to be affected by this alleged deficient practice. Staff Development Nurse/designee educated licensed staff on timely scheduling of appointments and assuring appointments are scheduled when ordered. Staff Development Nurse/designee re-educated licensed staff on administration of medications timely and documenting when administering medications. Unit Manager/designee will audit orders weekly x4 weeks then monthly x2 for outpatient specialist appointment orders and that they are scheduled timely and report findings to QAPI committee monthly. Unit manager/designee will complete random audit weekly of administration records to ensure that insulin is administered timely and report findings to QAPI committee monthly.