Failure to Follow Physician Orders and Document Insulin Administration
Penalty
Summary
The facility failed to provide necessary care and services to a resident with type 2 diabetes mellitus by not following physician's orders for medication administration and by failing to accurately document medication administration. Specifically, a Licensed Vocational Nurse (LVN) held multiple doses of Tresiba, a once-daily insulin medication, without a physician's order to do so. The nurse based the decision to hold the medication on the resident's blood sugar level, despite the absence of any such instruction in the physician's order. The nurse notified the Registered Nurse Supervisor about holding the medication, but the physician was not informed, and the facility's policy required a doctor's order before holding any medication not specified in the original order. Additionally, there was a failure in documentation when another LVN administered Tresiba to the same resident but did not record the administration in the Medication Administration Record (MAR) as required by facility policy. The resident confirmed receiving the medication, and the nurse also stated it was given, but the MAR did not reflect this. The facility's policy mandates that medication administration be documented immediately after administration, which was not followed in this instance.
Plan Of Correction
F0684 Quality of Care How corrective action will be accomplished for those residents found to have been affected by the identified practice: • On 8/9/25, Resident 1 was transferred to the hospital for further evaluation. • On 09/08/2025, 1:1 Inservice with LVN 1 regarding obtaining physicians' orders prior to holding medication. • On 09/08/2025, 1:1 Inservice with LVN 2 regarding accurate medication administration documentation. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: • All residents in the facility with long-acting insulin are potentially at risk of being affected. • On 09/08/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted an audit of all residents with orders for long-acting insulin to identify any instances of medication being withheld without a physician's order. • No other residents are affected by this deficient practice. On 09/08/2025, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) audited all medication administration records to ensure accurate documentation for residents with long-acting insulin orders: • No other residents are affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: • From 09/09/2025 to 09/12/2025, the Director of Nursing (DON) conducted in-service training for licensed nurses on the facility's medication administration policy and procedure, emphasizing the importance of obtaining a physician's order before withholding any medication. • From 09/09/2025 to 09/12/2025, the Director of Nursing (DON) conducted in-service training on accurate documentation practices for medication administration to ensure compliance with facility standards. • Starting on 09/10/2025, the DON and ADON will conduct random 3-5 times a week audits for any long-acting insulin withheld without a physician's order. • Starting 09/10/2025, the DON and ADON will conduct random 3-5 times a week audits for accurate documentation of all medication administration for all residents with long-acting insulin orders. • Any findings identified during the audits will be addressed promptly, and reeducation will be provided as necessary. A summary of each audit will be submitted to the DON and ED for review and follow-up. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: • The DON and ADON will be reporting the results of the monitoring to the QA committee monthly for three months for review and recommendations and to ensure substantial compliance is sustained. • Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.