Failure to Follow Professional Standards for Insulin Administration
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for a resident with diabetes mellitus, muscle weakness, and dysphagia. The resident was admitted with orders for both long-acting and short-acting insulin, but there was no documented order for a sliding scale or blood sugar parameters for insulin administration. Additionally, there was no evidence that blood sugar levels were checked prior to administering insulin lispro in the afternoon, as required by standard practice and facility policy. On one occasion, the resident experienced an episode of distress, with vital signs indicating low blood pressure and heart rate, and an oxygen saturation below normal. Paramedics found the resident's blood sugar to be 69 mg/dl, and the resident was subsequently sent to the hospital. The emergency department determined that the resident had experienced a hypoglycemic and mildly hypotensive episode, and recommended reducing insulin doses. Interviews with nursing staff confirmed that blood sugar checks were not performed prior to insulin administration, and that sliding scale and parameter orders were not in place as expected. Further review of facility policies indicated that nurses were required to check blood glucose per physician order or facility protocol and to notify providers of any discrepancies prior to administering insulin. The lack of sliding scale orders, blood sugar parameters, and failure to check blood sugar prior to insulin administration were confirmed by staff and the Director of Nursing. These omissions were not addressed until after the resident's hospitalization.