Failure to Administer Insulin per Physician Orders and Notify Provider
Penalty
Summary
The facility failed to administer insulin according to physician orders for a resident diagnosed with type 2 diabetes mellitus. The physician's order specified that the resident should receive 50 units of Insulin Glargine at bedtime and 5 units in the morning. Review of the medication administration records showed that on multiple occasions, the morning dose of insulin was not administered, and a chart code indicating 'Pulse below 60/min Ineffective' was documented. During interviews, an LPN confirmed holding the morning insulin dose due to low blood sugar and referenced parameters for another insulin, but did not notify the physician as required. The DON stated that staff are expected to follow insulin orders, and the APRN confirmed that they expect to be notified if insulin is held and that parameters should be followed.