Insulin Not Administered Per Physician Order
Penalty
Summary
A deficiency occurred when a licensed nurse failed to administer insulin lispro to a resident with type 2 diabetes according to the physician's order. The order specified that the insulin should be given subcutaneously before meals. During a medication pass observation, the nurse was seen preparing and administering the insulin after the resident had finished eating breakfast, rather than before the meal as prescribed. The nurse confirmed that the medication was given after the meal, despite the order and facility policy requiring administration before meals unless otherwise specified. The resident involved had a diagnosis of diabetes and was admitted to the facility in Fall 2022. Facility records and interviews with staff, including the DON, confirmed that insulin and blood sugar checks were expected to be performed prior to meals. The facility's medication administration policy also required medications to be given as prescribed and in accordance with good nursing practices, specifically noting that before or after meal orders should be administered based on mealtimes. The failure to follow these protocols resulted in the identified deficiency.