Failure to Administer Insulin and Monitor Blood Glucose per Physician Orders
Penalty
Summary
A deficiency was identified when the facility failed to follow physician's orders for the monitoring and administration of insulin for one resident. The resident, who had diagnoses including diabetes and was dependent on insulin, had physician orders for both long-acting and short-acting insulin, with specific instructions to check blood glucose prior to the administration of the 11:30 AM dose of short-acting insulin. The Medication Administration Record (MAR) showed that the 11:30 AM dose and the required blood glucose monitoring were missed on five out of fourteen occasions when the resident was out of the facility for dialysis. Interviews with the Director of Nursing (DON) revealed that the resident routinely left the facility three times a week for dialysis, departing by 10:00 AM and returning around 3:00 PM. The DON was not aware if the physician knew that the resident was missing the 11:30 AM insulin dose and associated blood glucose checks on those days. The DON acknowledged that the nurse documented the missed doses and monitoring but had not clarified the order with the prescribing physician to address the resident's regular absence during the scheduled administration time. The resident's primary physician confirmed awareness of the resident's dialysis schedule and insulin regimen but believed that blood glucose should be checked more frequently and that the missed doses were likely due to an oversight in order clarification. The physician stated he was under the impression that the resident would receive the insulin and monitoring upon return from dialysis. Staff interviews indicated that missed doses were considered as such and that clarifying the order with the physician would be the best course of action, but this had not been done.
Plan Of Correction
F684 Quality of Care What corrective action(s) will be accomplished for those residents found to have been affected by this practice? On medication review completed with NP. How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? On , Director of Nursing/designee completed an audit of all resident residents receiving to ensure supplemental orders are in place. On , Director of Nursing/designee completed an audit of all resident receiving to ensure a medication review has been completed. What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? By the Director of Nursing/ designee completed education with the licensed nursing staff regarding supplemental for monitoring, what to do if a medication is scheduled while a resident is at . How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? Director of Nursing/designee to complete random audit to ensure resident receiving have supplemental orders, weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Director of Nursing/designee to complete random audit to ensure a medication review has been conducted for resident receiving weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined. The practice will not recur; what quality measures will be put into place? Director of Nursing/designee to complete random audit to ensure resident receiving have supplemental orders, weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Director of Nursing/designee to complete random audit to ensure a medication review has been conducted for resident receiving weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.