Failure to Administer Insulin and Monitor Blood Glucose
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin and monitoring of blood glucose levels. Resident #202, who had a history of diabetes, end-stage renal disease, and anxiety, did not receive scheduled doses of Humalog and Lantus insulin, nor was their blood glucose monitored as per the provider's orders. This oversight led to the resident being found unresponsive with a critically high blood glucose level of 579, resulting in hospitalization for diabetic ketoacidosis. The incident occurred due to a series of lapses in communication and documentation among the nursing staff. On the morning of the incident, the scheduled nurse did not arrive on time, and the Registered Nurse Supervisor did not administer the morning medications, citing a lack of responsibility for the medication cart. The Licensed Practical Nurse Unit Manager, who arrived later, incorrectly documented that the resident was hospitalized at the time of the scheduled insulin doses, leading to the omission of critical medication administration and blood glucose monitoring. Interviews with the facility's staff, including the Director of Nursing, Physician Assistant, and Consultant Pharmacist, confirmed that the lack of insulin administration and blood glucose monitoring contributed to the resident's high blood glucose level and subsequent hospitalization. The Director of Nursing acknowledged that the facility's policies were not followed, and the Medical Director emphasized the importance of adhering to medical orders to prevent harm to residents.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 202 was sent to the hospital on [DATE] and did not return to the facility. Record review was completed for resident # 202 by the Director Of Clinical Operations and findings were shared with the QAPI Committee on meeting of 3/10/25. RN Supervisor # 1 was terminated on 11/10/24. Nurse who failed to administer Insulin and failed to perform blood glucose monitoring on 10/5/25 was LPN Unit Manager # 5. LPN Unit Manager # 5 was suspended on 2/13/25 and subsequently resigned on 2/13/25. The DON was counseled by the Director of Clinical Operations regarding review of medication omissions and records review of residents sent to hospital with change in condition. A review of residents sent to hospital in the last 30 days will be conducted - review will ensure that Insulin was given and blood glucose monitoring performed if indicated. Issues noted will be immediately addressed. All residents have the potential to be affected by the deficient practice. A full house review of residents receiving Insulin and blood glucose monitoring in the last 14 days will be completed. Any omissions and or issues noted will be immediately addressed. The policies for Medication Administration, Medication Administration Documentation and Medication Errors were reviewed by the Director of Clinical Operations with no revisions required. Education will be provided to all licensed nurses and will include: 1) Medication Administration and documentation 2) Medication errors 3) Medication errors reports and protocol 4) Need to notify DON and Medical provider of any medication omissions/errors 5) Ramifications of residents not receiving Insulin and or blood glucose checks 6) Review of Protocol for notifying DON/designee of staffing call ins requiring reassignment of nurses Licensed Nurses who do not attend the scheduled Education will be removed from the schedule until education is complete. The PCC Medication Administration Audit report will be reviewed daily at morning meeting. This audit allows for review of all medication omissions for a specified time frame. Omissions noted will be addressed and medication error reports completed as indicated. This audit will continue x 8 weeks. The RN Educator/designee will conduct Insulin and Blood glucose monitoring audits of 10 residents weekly x 12 weeks. Audits will ensure that Insulin is administered and blood glucose monitoring completed as per provider order. Audits will include all shifts and will include in person observations of staff. Issues noted will be immediately addressed. Residents sent to the hospital for change in condition will be reviewed by the DON/designee daily to ensure that there are no issues related to quality of care x 8 weeks. Audits/reviews will be shared with the QAPI Committee for review and input. QAPI Committee may continue audits based on findings. Responsibility: DON