Failure to Monitor and Intervene After Insulin Administration Resulting in Hypoglycemic Event
Penalty
Summary
A resident with severe cognitive impairment, heart failure, urinary tract infection, and diabetes mellitus was dependent on staff for most activities of daily living except eating and oral hygiene. The resident had physician orders for scheduled and sliding scale insulin, with instructions to monitor blood glucose as ordered. However, the care plan did not include directions for staff to observe for signs of hypoglycemia or hyperglycemia, nor did it specify actions to take if such signs were present. On the day of the incident, the resident was administered rapid-acting insulin before consuming her meal. Staff placed the lunch tray in front of the resident and verbally prompted her to eat, but she did not touch her food. The nurse who administered the insulin did not check on the resident again after the administration, and there was no follow-up to ensure the meal was consumed. Several hours later, the resident was found unresponsive with a critically low blood glucose level (25 mg/dL), and emergency medical services were called. Documentation was incomplete, with missing entries regarding the initial blood glucose reading and the administration of Glucagon. Interviews with staff revealed inconsistent understanding and implementation of insulin administration protocols, particularly regarding the timing of insulin relative to meals and the need for post-administration monitoring. Staff acknowledged that the resident typically ate better when assisted to sit up in a chair, but this was not addressed in the care plan. The facility's policy required monitoring and documentation of blood glucose and resident status after insulin administration, but these steps were not followed, contributing to the resident's hypoglycemic event and subsequent hospitalization.