Failure to Administer Sliding Scale Insulin and Monitor Blood Glucose
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and multiple comorbidities did not receive sliding scale insulin and appropriate blood glucose monitoring as ordered by the physician. The resident's Medication Administration Records (MAR) for several days showed no documentation of sliding scale insulin administration at scheduled times, despite an active physician order. The resident was also not consistently monitored for blood glucose levels during this period. Progress notes indicated that the sliding scale insulin order was not acknowledged in the electronic health record, leading nursing staff to believe it was discontinued, and as a result, the resident did not receive the prescribed insulin. This failure to administer insulin and monitor blood sugars resulted in the resident experiencing hyperglycemia, with blood sugar levels documented as high as 541, and ultimately being sent to the emergency room for evaluation and treatment. Interviews with nursing staff and the physician confirmed that the sliding scale insulin order was not confirmed in the system and was therefore not administered. The administrator acknowledged that orders should be reviewed and reentered correctly to ensure continuity of care, and that the resident should have received the sliding scale insulin as directed.