Failure to Notify Physician of Repeated Insulin Refusals
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident with Type 2 diabetes attained and maintained their highest practicable physical well-being. The resident had a physician's order for insulin Glargine to be administered at bedtime, with instructions to hold the medication if blood sugar was less than 90 mg/dl. Review of the Medication Administration Record (MAR) from April to June showed multiple instances where the resident refused the ordered insulin, as documented by nursing staff using the appropriate chart code for refusal. Despite these repeated refusals, there was no documented evidence that the physician was notified about the resident's consistent refusal of insulin. Facility policies required that medications be administered as ordered and that any refusal or withholding of medication be documented, with follow-up documentation as appropriate. During interviews, both the MDS Nurse and the Director of Nursing confirmed that there should have been documentation indicating the physician was informed of the resident's refusal to take insulin. The lack of physician notification was verified through closed medical record review and staff interviews.