Failure to Notify Physician When Insulin Held Due to Blood Sugar Levels
Penalty
Summary
The facility failed to notify a resident's physician when insulin doses were held due to blood sugar levels, as required. Record review for a resident with diagnoses including cellulitis, type 2 diabetes, and a pressure ulcer showed that Novolog insulin was ordered to be administered three times daily with meals. However, the Medication Administration Record indicated that the insulin was held on multiple occasions when the resident's blood sugar was below certain levels. There were no physician orders specifying parameters for holding the medication, no progress notes documenting the medication being held, and no evidence that the physician was notified when the insulin was not administered. Interview with the Director of Nursing revealed that the resident often refused insulin based on blood sugar readings, but the nurse should have documented these as refusals rather than holding the medication. The Director of Nursing confirmed there was no further information to provide regarding physician notification or documentation for the held doses.