Failure to Document Missed Insulin Doses and Notifications
Penalty
Summary
The facility failed to document in the clinical record when a prescribed medication, Humulin-R insulin, was not available for a resident with diagnoses including type 2 diabetes mellitus, end stage renal disease, and morbid obesity. The resident was admitted with orders to receive Humulin R U-500 insulin, which was later changed to Humulin-R insulin 100 units/mL, 40 units subcutaneously every evening. The Medication Administration Record (MAR) showed that the Humulin-R insulin was not administered on several dates, and notes indicated the medication was on order or not available. However, there was no documentation that the nursing supervisor, provider, or pharmacy were notified of the missed doses on these dates. Nursing notes indicated that on one occasion, after being unable to locate the insulin, the Advanced Practice Registered Nurse (APRN) was updated and directed staff to hold the dose, follow up with the pharmacy, and monitor blood sugars. Despite this, subsequent MAR notes for other missed doses did not reflect any notification to supervisory staff, providers, or the pharmacy. The facility's documentation policy requires nursing staff to complete documentation reflecting all care and services provided, including missed medications and related interventions, but this was not followed in the instances identified.