Failure to Accurately Document Insulin Use in Resident Assessments
Penalty
Summary
The facility failed to accurately document insulin usage for two out of four residents reviewed for assessments. One resident, admitted with diabetes and end stage kidney disease, had a physician order for Insulin Lispro to be administered before meals and at bedtime. However, the resident's quarterly Minimum Data Set (MDS) did not indicate the use of hypoglycemic medications, including insulin, in the section for high-risk drug classes, despite documentation of insulin administration in the electronic medical record. Similarly, another resident received insulin injections twice daily over a specified period, as recorded in the electronic medication administration record, and the MDS noted seven days of insulin injections. Nevertheless, the use of hypoglycemic medications was not documented in the high-risk drug class subsection of the MDS. These omissions were confirmed by the responsible nurse assessment coordinator during interviews.