Failure to Follow Insulin and Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to follow physician orders for insulin administration and blood glucose monitoring for a resident with type 2 diabetes and a history of atherosclerotic heart disease and coronary bypass graft. The resident had orders for Lantus insulin once daily, Insulin Lispro before meals and as needed per sliding scale, and blood glucose monitoring, including the use of a Freestyle Libre sensor. After returning from an endocrinology appointment, the resident's orders were updated to continue insulin and initiate the glucose monitoring device. However, Insulin Lispro was discontinued, and blood glucose monitoring was not performed as ordered. Review of the medication administration records showed that the resident stopped receiving Insulin Lispro and did not have blood glucose checks from the time the new orders were received until the time of the survey, except during blood draws. The resident reported that staff had not been monitoring her blood sugars and that her glucose monitoring device had come off, requiring a two-week wait for replacement. Interviews with facility staff and the endocrinologist's office confirmed that the orders were not clarified or followed, resulting in a lack of appropriate blood glucose monitoring and insulin administration.