Failure to Administer Glipizide According to Physician's Orders
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus and a history of long-term insulin use did not receive glipizide as ordered by the physician. The physician's order specified that glipizide should be administered 30 minutes before breakfast and dinner. However, the Medication Administration Record and audit reports showed that the medication was consistently given at 6:30 a.m., while the earliest breakfast was served at 8:00 a.m., resulting in the medication being administered up to one and a half hours before the resident ate. The resident expressed concerns to staff about the timing of the medication, stating that she was instructed by her physician to take glipizide within 30 minutes before breakfast and that taking it earlier could jeopardize her health. Despite her requests, nurses insisted on administering the medication at the scheduled time and did not offer it closer to breakfast or provide a snack. The resident did not refuse the medication but asked for it to be given at the appropriate time, and when this was not accommodated, she considered refusing it for her safety. Interviews with nursing staff revealed a lack of awareness regarding the resident's concerns and the physician's specific timing instructions. Staff acknowledged that medications intended to be given before meals should be administered closer to mealtime or with a snack if necessary, but this was not done. Facility policies required nurses to follow physician orders and to re-offer medications if initially refused, but these procedures were not followed in this case, resulting in a significant medication error.