Failure to Document and Administer Insulin per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with diabetes mellitus did not receive care and services in accordance with physician orders and professional standards. The resident was prescribed NovoLog insulin to be administered via a sliding scale based on blood glucose readings, with specific instructions for administration and documentation. On two consecutive days, the Medication Administration Record (MAR) did not document the administration of NovoLog or the monitoring of blood sugar, despite blood glucose readings being recorded elsewhere in the clinical record. On one of those days, the resident's blood sugar was elevated to a level that required insulin administration per the sliding scale order. Interviews revealed that the expectation was for all medication administration and monitoring to be documented on the MAR. The Director of Nursing confirmed that, according to a conversation with the nurse on duty, the insulin was administered on the day required, but this was not documented as required. The lack of documentation and failure to follow established protocols resulted in the facility not providing care and services in accordance with professional standards for the resident's physical, mental, and psychosocial needs.