Failure to Ensure Nursing Staff Competency with Insulin Pump Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to care for a resident using an insulin pump, resulting in immediate jeopardy to the resident's health and safety. The Director of Nursing confirmed that there was no policy in place for insulin pumps, and the facility's policy on competent nursing staff was not followed in this case. Clinical record review showed that a resident with multiple diagnoses, including diabetes, was admitted with an insulin pump, but the nursing admission evaluation did not document the presence of the pump, and the care plan did not address its management. Multiple interviews with RNs and LPNs revealed that none of the nursing staff, including agency staff, had received education or training on insulin pumps. Staff members were unfamiliar with the device, its maintenance, and its operation, with some only having personal knowledge from outside the facility. One LPN, who was working her first shift at the facility, transcribed hospital discharge orders incorrectly, entering the wrong insulin type and route of administration due to lack of training and orientation. This error led to the administration of insulin subcutaneously instead of refilling the pump, resulting in the resident experiencing hypoglycemia and requiring hospital transfer for an accidental insulin overdose. The employee file for the LPN who made the error did not contain evidence of facility orientation or training on the admission process, order transcription, or insulin pump management. The Director of Nursing and Nursing Home Administrator confirmed that staff were not trained on insulin pumps or related processes, and that this lack of training and competency directly resulted in a negative outcome for the resident.
Removal Plan
- Audit residents to identify specialty equipment. If specialty equipment is identified, obtain physician orders. Update care plans to include specialty equipment if applicable.
- Audit admission assessments for residents for special equipment specifically insulin pumps and/or continuous glucose monitors.
- Audit physician orders from discharge paperwork for residents for accuracy.
- Conduct pre-admission resident screening to identify any special equipment. Communicate special equipment needs to the nursing team prior to resident admission. Educate Admissions Director on this process.
- Educate licensed nursing staff (including agency) on conducting pre-admission resident screening to identify any special equipment and communicating special equipment needs to the nursing team prior to resident admission.
- Educate licensed nursing staff (including agency) on assessing residents upon admission for special equipment including insulin pumps/continuous glucose monitors.
- Educate licensed nursing staff (including agency) on obtaining physician orders for specialty equipment.
- Educate licensed nursing staff (including agency) on accurate order transcription and admission red lining processes.
- Educate licensed nursing staff (including agency) on care plan updates on specialty equipment.
- Educate licensed nursing staff (including agency) on updated processes.
- Update and review facility policy on medication administration to include specialty equipment, obtaining physician orders, and updating care plans.
- Conduct audits of new resident admission assessments to ensure assessments, redlining, and orders are completed and accurate.
- Submit findings of audits through facility Quality Assurance and Performance Improvement program.