Failure to Follow Physician's Orders for Insulin Administration
Penalty
Summary
Facility nurses failed to follow physician's orders for a resident who was admitted with multiple diagnoses, including difficulty swallowing and high risk for complications. The resident required specific monitoring and medication administration, including Lispro insulin. During a medication administration observation, an LPN was unable to locate the resident's Lispro in the medication cart and the emergency medication kit did not contain it. The LPN contacted the physician and obtained orders to hold the Lispro and re-check the resident's blood sugar every hour until the refill arrived from the pharmacy. However, the LPN did not document any re-checks in the medical record, and the next recorded blood sugar check was four hours later by another LPN. The Unit Manager confirmed the lack of documentation and acknowledged the failure to follow the physician's orders. The Director of Nursing emphasized the importance of monitoring residents to prevent complications and re-hospitalization. The facility's standards required nurses to evaluate and document the resident's status, which was not adhered to in this case.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or the conclusions set forth in the Statement of Deficiencies rendered by the reviewing agency. The Plan of Correction is prepared and executed solely because it is required by the provisions of federal and state law. Avante at Melbourne maintains the alleged deficiencies do not individually jeopardize the health and/or safety of its residents nor are they of such character as to limit the provider's capacity to render adequate resident care. Furthermore, Avante at Melbourne asserts that it is in substantial compliance with regulations governing the operation of long-term care facilities, and this Plan of Correction in its entirety constitutes the provider's credible allegation of compliance. A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On an assessment was completed on resident number 93 no signs or symptoms of hyper or were noted. b. On staff member received education on entering physician orders in the medical record when received orders for abnormal lab results. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit to ensure resident with order changes related to abnormal results ensure all orders are followed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/designee completed education with licensed nurses when orders are received related to abnormal results a physician order is placed in the resident medical record. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure resident with order changes related to abnormal results ensure all orders are followed compliance with N054 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.