Failure to Administer Insulin and Monitor Blood Glucose as Ordered
Penalty
Summary
The facility failed to ensure that blood glucose levels were obtained before meals and that insulin was administered prior to meals as ordered for three residents with diabetes. Physician orders for each resident specified that blood glucose monitoring and insulin administration should occur before meals, with specific sliding scale instructions or set doses. However, review of medication administration records revealed that insulin was frequently given at times not aligned with scheduled meal times, including after meals or significantly delayed from the prescribed schedule. For example, one resident with severe cognitive impairment and diabetes had insulin administered at times such as 10:00 AM and 12:05 PM, which did not correspond with the scheduled breakfast or lunch times. Another resident, who was dependent on staff for activities of daily living, received insulin doses at times such as 10:36 AM and 7:11 PM, rather than with meals as ordered. A third resident with severe cognitive impairment and diabetes also received insulin at times inconsistent with meal schedules, such as 5:56 PM and 1:10 PM, rather than before or with meals as directed by the physician. Interviews with nursing staff and the Director of Nursing Services confirmed that the facility's standard practice was to check blood glucose prior to meals and administer insulin either thirty minutes before or with meals. Despite these policies, documentation and staff interviews indicated that these practices were not consistently followed, resulting in the failure to meet professional standards of quality for medication administration as required by facility policy and physician orders.