Failure to Notify Physician of Insulin Refusal
Penalty
Summary
A deficiency was identified when a nurse failed to notify the physician on call regarding a resident's repeated refusal of prescribed insulin. The resident, who had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure, had a physician order for 6 units of insulin aspart to be administered subcutaneously before meals, unless blood glucose was below 100. During observation, the nurse checked the resident's blood glucose, found it to be 169, and noted that the resident had been refusing insulin due to previous hypoglycemic episodes. The nurse documented the refusal and monitored the resident but did not notify the physician of the refusal. Upon interview, the nurse acknowledged that physician notification should occur when insulin is refused, as this could prompt a reassessment of the medication order. Review of the resident's progress notes confirmed that the provider was not contacted regarding the refusal. The Director of Nursing confirmed that the facility's expectation is for nurses to notify the provider every time insulin is refused, to allow for potential adjustment or discontinuation of the medication.