Failure to Administer and Document Insulin for Diabetic Residents
Penalty
Summary
The facility failed to ensure that multiple residents were free from significant medication errors, specifically regarding the administration of insulin for diabetic residents. For four out of five residents reviewed, there were documented omissions in the administration of prescribed insulins, including Glargine, Lispro, Novolog, and Lyumjev, as well as failures to perform required blood glucose checks. These omissions were identified through review of Medication Administration Records (MARs) for the months of January, February, March, and April, where blank entries indicated that medications were not administered as ordered. In several instances, there was no documentation or explanation for the missed doses, and staff interviews did not provide satisfactory clarification for the omissions. The residents involved had significant medical histories, including diagnoses of Type 2 diabetes, hypertension, obesity, muscle weakness, and other comorbidities. Their care plans included interventions such as routine insulin administration and blood glucose monitoring. Despite these documented needs, the MARs reflected multiple days where insulin and blood glucose checks were not recorded as given. Interviews with the residents revealed that they generally believed they were receiving their medications as scheduled, and none recalled missing doses or experiencing related adverse events during the review period. Staff interviews revealed inconsistent explanations for the missing documentation. Some staff cited issues with the electronic medical record system (PCC) during a change of ownership, particularly in January, which may have affected MAR documentation. However, omissions were also noted in subsequent months, and staff were unable to provide clear reasons for these gaps. The DON confirmed the presence of blank MAR entries and was unable to locate alternative proof of administration for the missing doses. Facility policy requires that all medication administrations be documented and that any omissions be explained in the resident record, which was not consistently done in these cases.