Failure to Ensure Annual Insulin Administration Competencies and Protocol Adherence
Penalty
Summary
The facility failed to implement its facility assessment to ensure that all licensed nurses, including one LPN and potentially eight others, who administered insulin had completed yearly competencies for safe insulin administration and identification of complications related to blood sugar levels. This deficiency was identified through interviews and document reviews, which revealed that the facility did not maintain up-to-date competency records for insulin administration or for recognizing and responding to hypoglycemia or hyperglycemia. The facility assessment did not specify that staff should be deemed competent at least yearly or more often as necessary, and there was no evidence of annual competencies for 2024 for the involved LPN. A resident with multiple comorbidities, including diabetes mellitus type 2, heart failure, chronic kidney disease, and hypertension, experienced a significant event related to improper insulin administration. The resident received rapid-acting insulin (Fiasp) and long-acting insulin (Glargine) prior to receiving his meal, contrary to manufacturer instructions and facility protocols. The resident was found sweating, drooling, and unable to answer appropriately after receiving insulin before his meal was served. Blood sugar monitoring showed a drop from 99 mg/dL to 68 mg/dL, and upon arrival at the emergency department, the resident's blood sugar was 33 mg/dL. The facility's progress notes lacked documentation of the resident's blood sugar at the time of the incident and did not specify what interventions were implemented before the resident was sent to the hospital. Interviews with nursing staff revealed uncertainty regarding protocols for insulin administration and management of low blood sugar. The LPN involved was not aware of the availability of glucagon injectable medication and did not follow the standing order protocol for severe hypoglycemia, instead attempting to give the resident juice and sugar packets. The facility's policies did not provide clear guidance on recognizing diabetic complications or following manufacturer guidelines for insulin administration. The director of nursing confirmed that the LPN did not follow proper procedures and that not all nursing staff had received annual competencies related to insulin administration.