Failure to Administer Insulin and Notify Physician of Abnormal Blood Glucose
Penalty
Summary
The facility failed to ensure proper administration of insulin and timely physician notification regarding elevated blood glucose levels for two residents with diabetes. For one resident with a history of myocardial infarction, atrial fibrillation, hypertension, and type 2 diabetes, physician orders required nightly administration of Insulin Glargine. However, the medication administration record showed extremely high blood sugar readings on multiple occasions, with no documentation that the physician was notified as required. Nursing staff interviews confirmed that insulin was not administered when blood sugar was outside parameters, and there was no evidence of physician notification or documentation in the medical record. For another resident with type 2 diabetes and diabetic neuropathy, physician orders specified nightly Lantus insulin without hold parameters. Despite this, the insulin was held on several occasions when blood sugar readings were low, and the nurse cited sliding scale parameters that were not present in the physician's order. Review of the facility's medication administration policy confirmed that medications are to be given as ordered by the physician. The failure to administer insulin as ordered and to notify the physician of abnormal blood glucose values constituted a deficiency in following physician orders and facility policy.