Failure to Hold Insulin Doses per Physician Order
Penalty
Summary
The facility failed to ensure that insulin doses were withheld when blood glucose readings were below the physician-ordered hold parameter for a resident with type 2 diabetes mellitus, diabetic nephropathy, and chronic kidney disease. The physician's order specified that 35 units of Fiasp FlexTouch U-100 Insulin should be administered three times daily, but included instructions to hold the dose if the blood sugar was below 130. Despite this, the Medication Administration Records showed that insulin was administered multiple times when the resident's blood sugar was below the specified threshold. Interviews with nursing staff confirmed that insulin should have been held according to the order, and the facility did not have a specific policy regarding insulin administration or adherence to physician-ordered hold parameters at the time of the incidents. The facility's general medication administration policy referenced the 'right dose' but did not address the specific issue of holding medications based on blood sugar readings.