Failure to Administer Insulin as Prescribed for Two Residents
Penalty
Summary
The facility failed to ensure that insulin was administered as prescribed for two residents with diabetes and other significant medical conditions. For one resident, there were multiple instances where insulin doses were either administered late or omitted entirely. Specifically, Humalog and Lantus insulins were not given at the times ordered by the physician, with some doses being delayed by several hours and one morning dose not administered at all. Documentation showed that staff did not provide a reason for these deviations from the prescribed schedule. For the second resident, Lantus insulin ordered for bedtime was repeatedly administered several hours late, often during the early morning hours of the following day. Additionally, scheduled doses of Humalog were not administered on several occasions despite the resident's blood sugar levels being above the threshold specified in the physician's order. Facility guidelines required medications to be administered according to physician orders and documented at the time of administration, but these protocols were not followed in the cases reviewed.