Failure to Develop Individualized Care Plan for Insulin Pump Use
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident who was using an insulin pump for diabetes management. Although the resident's care plan included general interventions for diabetes, such as education on hypo/hyperglycemia and regular blood glucose monitoring, it did not address the specific needs and interventions related to the continuous use of an insulin pump. The care plan omitted critical information about the insulin pump, including its presence and the continuous infusion of insulin, despite this being part of the resident's prescribed treatment. As a result of this omission, a nurse administered 90 units of Humulin insulin subcutaneously instead of using it to refill the insulin pump, leading to the resident experiencing hypoglycemia and requiring hospital transfer for an accidental insulin overdose. Interviews with facility leadership confirmed that there was no care plan in place for the insulin pump, and the facility did not provide individualized interventions to address the resident's specific care needs related to the device.