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F0658
D

Failure to Administer Insulin According to Physician Orders and Professional Standards

Taylor, Pennsylvania Survey Completed on 04-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A registered nurse failed to provide nursing services consistent with professional standards of quality by not following physician's orders and not ensuring accurate medication administration for a resident diagnosed with Type 2 Diabetes Mellitus and parkinsonism. During a medication administration observation, the nurse checked the resident's blood sugar, which was 169 mg/dL, and administered 10 units of Novolog insulin. However, the physician's sliding scale order for Novolog required administration only when blood glucose readings exceeded 200 mg/dL, and the resident's blood sugar did not meet this criterion. Additionally, the nurse was supposed to administer Basaglar, a long-acting insulin, as per the active physician order, but this medication was not available on the medication cart at the time of inspection. A review of medication usage showed that Novolog insulin had been administered multiple times without qualifying blood sugar levels, and the nurse documented that Basaglar was given when it was not. The nurse admitted to failing to verify the medication type against the physician's orders prior to administration. The Director of Nursing confirmed that the nurse did not verify the insulin type, administered the incorrect medication, and failed to provide nursing services in accordance with professional standards of practice.

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