Failure to Administer Medications and Monitor Blood Sugars as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for three residents with diabetes and hypotension. For one resident with insulin-dependent diabetes, there were multiple instances where blood sugar levels were not monitored as ordered, insulin doses were not administered, and there was a lack of documentation explaining these omissions. In several cases, when blood sugar readings were outside of the prescribed parameters, there was no evidence that the physician was notified, and in at least one instance of low blood sugar, there was no documentation of treatment, rechecking, or physician notification as required by facility guidelines. Another resident with diabetes had physician orders for blood sugar checks and insulin administration based on a sliding scale. The record showed that on several occasions, midday blood sugars were not checked and insulin was not administered, with no documentation in the nurses' notes to explain these omissions. The Director of Nursing confirmed that these required checks and treatments were not completed as ordered. A third resident with a diagnosis of hypotension had a physician order to hold a specific blood pressure medication if the blood pressure was below a certain threshold. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the ordered limit. The Director of Nursing acknowledged that the medication should not have been given under these circumstances. The facility's medication administration policy required medications to be given in accordance with prescriber orders, which was not followed in these cases.