Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer insulin as ordered for a resident with Type II Diabetes Mellitus. According to the Medication Administration Records (MARs) and physician orders, the resident was prescribed both Insulin Aspart and Humalog insulin to be given subcutaneously before meals, with additional sliding scale dosing based on blood glucose levels. The MARs documented multiple instances where the resident did not receive the prescribed doses of Insulin Aspart and Humalog at the specified times. Additionally, on at least one occasion, the sliding scale dose of Insulin Aspart was not administered when the resident's blood sugar reading indicated it was required. Interviews with the resident's physician and the Director of Nursing confirmed that the insulin doses were missed and that this constituted a medication error. The facility's own policy requires medications to be administered accurately and according to physician orders, but this was not followed in the resident's case, as evidenced by the documented omissions in the MARs.