Failure to Administer Insulin as Ordered and Incomplete Narcotic Shift Counts
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for one resident by not administering insulin as ordered by the physician. Medical record review showed that the resident had a physician's order for Humulin R insulin to be given subcutaneously before meals based on specific blood sugar levels. On two occasions, the resident's blood sugar was above the threshold requiring insulin, but the medication was not administered, and the medication administration record was incorrectly coded to indicate that no insulin was required. Both the LVN and RN involved acknowledged that insulin should have been given according to the physician's order. Additionally, the facility did not ensure proper accounting and safeguarding of controlled medications. Review of the Narcotic Shift Count sheets for one medication cart revealed multiple instances over several months where the required signatures from incoming and outgoing licensed nurses were missing. This failure to complete the narcotic count documentation was verified by staff and acknowledged as a risk for medication errors and drug diversion. The facility's policies required these counts and signatures to be completed at every shift change, but this was not consistently done.