Failure to Notify Physician and Resident of Unavailable Insulin
Penalty
Summary
A resident with diagnoses including type 2 diabetes mellitus, atrial fibrillation, and multiple sclerosis did not receive prescribed doses of long-acting insulin (Lantus) on two consecutive evenings. The resident, who was cognitively intact, reported not receiving the medication and not being given an explanation. Documentation showed that the insulin was unavailable due to a pharmacy refill issue and was not present in the emergency drug kit. The Medication Administration Record and electronic notes indicated the medication was not administered, but there was no documentation that the physician or the resident had been notified of the unavailability. Interviews with facility staff confirmed that the nurse on duty had contacted the pharmacy and attempted to notify the on-call Nurse Practitioner via text message, but there was no documentation to support that the physician or the resident had been formally informed about the missed doses. Progress notes for the relevant dates also lacked evidence of such notifications. This failure to notify both the physician and the resident of the medication's unavailability constituted the deficiency.