Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to ensure that insulin was administered according to physician orders for two residents with diabetes. For one resident, the physician order specified that insulin should be held if blood sugar was less than 150, yet there were eighteen documented instances where insulin was administered despite blood sugar readings below this threshold. The resident's care plan indicated diabetes management with medication as ordered, and the MARs showed repeated administration of insulin when blood sugar was less than 150. Staff interviews revealed that nursing staff did not consistently follow the parameters set by the physician order, with one RN stating disbelief in the necessity of the parameters and another indicating that administration was based on dietary intake rather than the specified blood sugar threshold. For the second resident, the physician order also required insulin to be held if blood sugar was less than 150, but the MARs documented multiple instances over several months where insulin was given despite blood sugar readings below this level. Staff interviews indicated a lack of awareness or understanding of the parameters for insulin administration, with some staff believing that only certain residents had such parameters. The Director of Nursing and Administrator confirmed that there was no facility policy addressing medication administration in these circumstances. Both residents had documented cognitive impairments and required insulin injections as part of their diabetes management.