Failure to Notify Physician When Insulin Held
Penalty
Summary
The facility failed to ensure that a physician was notified when insulin was held for a resident with diabetes mellitus. According to the resident's physician order, Lantus insulin was to be administered daily and held if the fingerstick blood sugar (FSBS) was below 120. Medication administration records showed that the insulin was not given on multiple dates because the resident did not eat breakfast, but there was no documentation that the physician had been notified of these omissions. An LPN confirmed that insulin would be held if a resident was not eating or if their blood sugar was low, and that the physician should be notified and the event documented in the progress notes. However, there was no evidence that this notification or documentation occurred for the resident in question.