Failure to Administer Insulin and Perform Blood Glucose Monitoring per Hospice Orders
Penalty
Summary
A resident was admitted for a 5-day respite stay under hospice care with multiple diagnoses, including cerebrovascular disease, hypertension, anxiety disorder, atrial fibrillation, and depression. Upon admission, a hospice order summary indicated prescriptions for Lactaid, Glucerna, and sliding scale insulin. However, review of the Medication Administration Record and Treatment Administration Record for the resident's stay revealed that insulin was not administered and blood glucose monitoring was not performed during the entire period. Progress notes and interviews with nursing staff confirmed that the hospice order summary, which included the sliding scale insulin instructions, was not uploaded into the resident's clinical record until after discharge. Staff were unable to locate any physician's order for insulin in the resident's record during the stay, and as a result, insulin was not given. The medication reconciliation process failed to capture the insulin order, and the omission was not identified until the resident reported to nursing staff that insulin was expected. Interviews with the DON, RN, and LPN staff revealed that the facility's process for reviewing and transcribing physician and hospice orders was not followed as required. Staff acknowledged that the admitting nurse is responsible for verifying incoming orders and that the failure to administer insulin and perform blood glucose testing constituted a medication error. Facility policies require medications to be administered according to written orders and for all orders to be accurately transcribed and recorded, which did not occur in this instance.