Failure to Administer and Document Insulin According to Physician Orders
Penalty
Summary
The facility failed to ensure that insulin and other diabetes medications were administered and documented according to physician orders for four residents. Multiple observations, record reviews, and interviews revealed that insulin doses were frequently given outside of the prescribed time frames, with some doses being administered several hours late or not documented at all. Residents reported inconsistent administration times, with some indicating they received insulin before meals as ordered, while others were unsure of the timing or reported significant delays. Staff interviews confirmed that medications were sometimes administered late due to workload and that documentation was not always completed at the time of administration. Medical record reviews for the affected residents showed repeated instances where insulin was administered well outside the one-hour window before or after the scheduled time, as required by facility policy. For example, insulin doses scheduled for early morning or before meals were often given in the late morning, afternoon, or even evening. In some cases, there was a complete lack of documentation for certain insulin administrations, including STAT orders for hyperglycemia. The medication administration records (MARs) reflected numerous late entries and missing documentation for both scheduled and sliding scale insulin doses. The residents involved had diagnoses of type 2 diabetes mellitus, some with complications such as diabetic neuropathy or chronic kidney disease, and were assessed as requiring regular insulin injections. Care plans for these residents included interventions to administer diabetes medications as ordered, but these interventions were not consistently followed. Staff interviews indicated that high workload and the need to cover multiple halls contributed to the delays. The facility's medication administration policy required medications to be given within a specific time frame and for documentation to be current, but these standards were not met for the residents reviewed.