Failure to Provide Timely Insulin Administration Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when the facility failed to ensure that prescribed insulin medications were available and administered in a timely manner to a resident with type 1 diabetes. Upon admission following an acute hospitalization, the resident had orders for both long-acting and fast-acting insulin, including Basaglar and Novolog, to be administered at specific times and per sliding scale. Documentation in the electronic Medication Administration Record (eMAR) showed that several scheduled doses were not administered, with staff using a code indicating the medication was not given and referencing nurses' notes for further explanation. Review of the eMAR and associated progress notes revealed that the insulin was not available in the facility at the required times, resulting in missed doses. Staff documented that they were awaiting delivery from the pharmacy and that the nurse practitioner and physician were notified of the unavailability. Blood sugar checks during this period showed elevated glucose levels, and staff continued to monitor the resident for symptoms of hyperglycemia. Despite these actions, the prescribed insulin was not administered as ordered due to the lack of medication on hand. Additionally, there was a discrepancy in the documentation, as one administration time was marked as given despite other records indicating the insulin was not available. The facility's leadership, including the Nursing Home Administrator and Director of Nursing, were informed of the missed administrations and the documentation inconsistency. No further comments were provided by the facility leadership at the time of the survey.