Failure to Monitor Respiratory Status and Adhere to Insulin Administration Protocols
Penalty
Summary
Nursing staff failed to provide necessary care and services to several residents, resulting in multiple deficiencies. For one resident with chronic respiratory conditions, including COPD and emphysema, the care plan required monitoring and documentation of respiratory rate at least once per shift. However, on three consecutive days, there was no documentation of the respiratory rate, despite the resident's care plan and facility policy specifying this requirement. Interviews with staff, including CNAs, LVNs, the Director for Staff Development, and the DON, confirmed that vital signs, including respiratory rate, should have been taken and documented for residents with lung disease. Additionally, for four other residents with diabetes, nursing staff did not rotate subcutaneous insulin injection sites as required by facility policy and provider orders. Review of medication administration records (MARs) showed repeated administration of insulin in the same anatomical locations over extended periods, rather than rotating sites for each dose. This practice was confirmed by the DON during record review and interviews, who acknowledged that injection sites should have been rotated for every dose. Furthermore, for two of these residents, nursing staff did not notify the physician when blood sugar results were below 70 mg/dl, as required by the provider's insulin sliding scale orders. Documentation review revealed multiple instances where blood sugar readings fell below the threshold, but there was no evidence of physician notification or documentation of such communication. The DON and LVN interviewed confirmed that staff were expected to notify the physician and document the communication when low blood sugar levels occurred, but this was not done.