Failure to Recheck Blood Glucose After Insulin Administration
Penalty
Summary
The facility failed to follow the care plan for a resident with diabetes mellitus and hypoglycemia by not rechecking blood glucose levels after administering insulin, as required by the resident's care plan. The care plan specified that blood sugar should be rechecked 30 to 45 minutes after insulin administration to monitor for hypo- or hyperglycemia. Record review and interviews confirmed that on multiple occasions, insulin was administered to the resident for elevated blood sugar levels, but no subsequent blood glucose checks were performed as directed in the care plan. The resident had intact cognition and required assistance with daily activities, including eating, oral hygiene, toileting, and showering. The failure to recheck blood glucose was acknowledged by both the RN and the DON during interviews, and the facility's policy required comprehensive, person-centered care plans with measurable objectives to be implemented. The omission of post-insulin blood glucose monitoring was directly contrary to the established care plan and facility policy.