Failure to Document Assessment for Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure thorough documentation of an assessment regarding a resident's ability to self-administer insulin. Clinical record review, policy review, and staff interviews revealed that a resident with diagnoses including diabetes, hypertension, and Parkinson's disease was self-administering insulin without comprehensive documentation of an assessment to determine if this was clinically appropriate. Although the resident had an intact cognitive status as indicated by a perfect BIMS score, the care plan did not document the resident's ability to self-administer insulin, and the facility's policy required such an assessment. Staff interviews indicated that nursing staff either handed the insulin to the resident or left it on his table, and the resident administered it himself, particularly after refusing to have certain staff administer his insulin. The Director of Nursing was unaware if a formal assessment had been documented, and only a brief handwritten note was found stating the resident had self-administered insulin and "did fine." No further details or formal assessments were available, and it was unclear if staff observation was required during administration. The lack of detailed documentation and assessment constituted the deficiency.