Failure to Administer Insulin as Ordered and Notify Provider
Penalty
Summary
The facility failed to ensure that insulin administration services met professional standards of practice for one resident with type II diabetes. Physician orders specified that insulin lispro was to be administered subcutaneously at specific times each day, with no parameters provided for withholding the medication. Record review showed that on three separate occasions, the insulin was not administered as ordered, despite documented blood sugar levels. There was no evidence in the records that the provider was notified when the insulin was not given on these dates. Interviews with staff confirmed that the insulin should have been administered as ordered and that any deviation, such as holding the medication, should have been reported to the provider. The LPN acknowledged the absence of parameters to hold the insulin, and the DON was unable to provide evidence that the medication was administered as ordered. The nurse practitioner also stated that she expected to be notified if the medication was held. These findings indicate that the facility did not follow physician orders or notify the provider when the insulin was not administered.