Failure to Administer Insulin, Complete Skin Assessments, and Perform Post-Fall Neurological Checks
Penalty
Summary
The facility failed to provide care and treatment according to physician orders and established protocols for multiple residents. For two residents with diabetes, insulin was not administered as ordered by the physician on specific dates, and blood sugar checks were omitted. One of these residents also did not receive a weekly skin assessment as required, with a gap of 13 days between assessments, despite being at moderate risk for skin breakdown. Staff interviews confirmed that weekly skin assessments and insulin administration were not consistently performed as ordered. Additionally, the facility did not complete required neurological checks after falls for two residents. One resident, who had a history of dementia and falls, experienced a fall with head injury and was sent to the emergency room. Upon return, the neurological check sheet showed multiple omissions in the required monitoring intervals. Another resident, who was at risk for falls and had an unwitnessed fall, did not have any neurological checks documented after the incident. Staff interviews confirmed that neurological checks were not consistently completed following falls. Facility policies required that insulin be administered according to physician orders and that full body skin assessments be performed weekly for residents at risk of pressure ulcers. The facility also had protocols for post-fall neurological monitoring, especially after unwitnessed falls or head injuries. Despite these policies, the clinical records and staff interviews revealed that these protocols were not followed for the affected residents.