Failure to Follow Physician Orders for Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with diabetes and a history of ketoacidosis did not receive care according to physician orders. The resident required regular blood glucose monitoring and insulin administration before meals, with specific instructions to hold insulin if blood sugar was below 90 or if less than 25% of a meal was consumed. On the morning in question, the Medication Administration Record (MAR) showed that the 8:00 AM blood sugar check and insulin injection were not completed. The LPN assigned to the unit had been reassigned late and did not perform the required tasks, while the RN supervisor, who temporarily covered the unit, did not administer medications or conduct blood sugar testing before leaving the facility to obtain medication for another resident. The Director of Nursing was not aware of the omission until later, and the facility's policies required medications to be administered within a two-hour window and blood glucose monitoring to be performed as ordered. The failure to follow physician orders for blood glucose monitoring and insulin administration was confirmed through review of the MAR, interviews with nursing staff, and facility documentation. The resident's care plan specifically included diabetes management interventions, but these were not implemented as required on the day of the incident. The omission was later documented as a medication error by the facility.