Failure to Monitor and Document Insulin Parameters and Adverse Effects
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of adverse side effects and parameters for insulin administration for one resident receiving insulin therapy. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that there were no documented orders or ongoing monitoring for signs and symptoms of hypoglycemia or hyperglycemia, despite the resident receiving scheduled doses of insulin Glargine and Humalog. The resident's care plan included interventions to monitor for symptoms of both hypoglycemia and hyperglycemia, but this was not reflected in the MAR or TAR, and staff interviews confirmed that there was no documentation of such monitoring. Additionally, the insulin orders for the resident did not include specific parameters for when to hold the medication or notify the provider based on blood glucose levels. Staff interviews, including those with the Resident Care Manager and Director of Nursing Services, confirmed that they expected such parameters to be present and that the lack of these parameters and monitoring was not in accordance with facility policy. The absence of documented monitoring and clear parameters for insulin administration constituted a failure to comply with requirements for safe medication management.