Failure to Implement and Review Hospital Discharge Orders for Insulin Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's total program of care, including medications and treatments, was properly reviewed and implemented by the medical provider upon readmission from the hospital. The resident, who had diagnoses of diabetes and end stage kidney disease, was discharged from the hospital with specific instructions for sliding scale insulin administration based on blood glucose readings, as well as scheduled fingerstick blood glucose monitoring. However, upon readmission, the sliding scale insulin orders were not initiated, and fingerstick monitoring was not consistently performed as ordered. Documentation showed that the admitting nurse and nurse practitioner reviewed and altered the hospital discharge orders, discontinuing the sliding scale insulin and opting to monitor blood glucose with long-acting insulin only. There was no evidence that the provider was aware of or addressed the hospital's recommendations for sliding scale insulin. Additionally, the resident's blood glucose readings were frequently elevated, and there were multiple instances where fingerstick checks were missed according to the Medication Administration Record. Despite these high readings and missed checks, there was no documentation that the provider was informed or that the care plan was adjusted accordingly. Interviews with facility staff revealed a lack of clarity and communication regarding the hospital discharge orders and the need for sliding scale insulin. The nurse practitioner stated they were not notified of blood sugar issues and believed the sliding scale should have been implemented per the hospital endocrinologist's orders. The admitting nurse acknowledged discontinuing the insulin due to the resident's nausea and vomiting, but the process for reviewing and finalizing orders was not clearly documented. Ultimately, the resident was readmitted to the hospital with hyperglycemia after being found lethargic with extremely high blood glucose levels.