Failure to Administer Insulin Prior to Meals as Ordered
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors when they did not receive their prescribed insulin prior to eating their meals, as ordered by their physicians and recommended by the manufacturer. Observations revealed that a registered nurse was delayed in checking blood sugar levels and administering insulin, resulting in insulin being given after the residents had already begun or finished their meals. In one instance, a nurse was observed checking a resident's blood sugar after the meal had started, and insulin was administered during the meal. In other cases, residents had already eaten before their blood sugar was checked and insulin was administered. The residents involved had complex medical histories, including type II diabetes mellitus, cognitive impairments, and other significant health conditions such as heart failure, acute respiratory failure, hemiplegia, and amputations. Assessments indicated that two of the residents were severely cognitively impaired, while one was moderately impaired. Physician orders for all three residents specified that insulin should be administered subcutaneously before meals, and this was not followed in the observed incidents. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for blood sugar checks and insulin administration to occur prior to meals to ensure accurate dosing and effectiveness. The facility's job description for registered nurses also required medication administration in accordance with physician orders and regulatory standards. Reference materials reviewed by surveyors supported the need for insulin to be administered before meals, as deviations could result in significant health risks.