Failure to Hold Insulin per Physician Order
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Record review showed that a resident with diabetes and hypertension was prescribed seven units of insulin Aspart subcutaneously before meals, with instructions to hold the dose if blood glucose was less than 140 mg/dl. Despite this order, documentation revealed that the resident was administered the insulin on multiple occasions when her blood glucose was below the specified threshold. The Director of Nursing confirmed that, according to the documentation, insulin was given when it should have been held.