Failure to Administer Insulin as Ordered for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not administering insulin as ordered. According to the facility's policy, medications are to be administered safely, timely, and as prescribed, including following the prescriber's orders regarding timing. Review of the medical record for a resident with multiple diagnoses, including diabetes mellitus and severe cognitive impairment, showed a physician's order for Regular Insulin to be administered subcutaneously if blood sugar exceeded 300 mg/dL. Documentation revealed that on two occasions, the resident's blood sugar readings were significantly above the threshold (425 mg/dL and 381 mg/dL), but there was no evidence that insulin was administered as ordered. The DON confirmed in an interview that the insulin was not given when the resident's blood sugar was greater than 300 mg/dL, as required by the physician's order.