Insulin Administered Outside Physician Parameters
Penalty
Summary
Staff failed to follow a physician's order regarding the administration of insulin for a resident with multiple diagnoses, including diabetes mellitus, hypertension, and impaired cognition. The physician's order specified that insulin glargine should be held if the resident's blood glucose was less than 120 mg/dl. Despite this, the Medication Administration Record (MAR) documented multiple instances in April and May where insulin was administered when the resident's blood glucose was below the ordered threshold. These instances were confirmed by review of the MAR and by a licensed nurse who acknowledged that insulin had been given outside of the prescribed parameters. The resident's care plan directed staff to monitor blood glucose as ordered, administer diabetes medication as directed by the physician, and monitor for side effects and effectiveness. Facility policy required staff to verify orders, document results, and follow appropriate nursing interventions based on blood sugar results. Interviews with nursing staff and administration confirmed that staff were expected to follow physician orders, but the records showed repeated failures to do so, resulting in the administration of unnecessary medication.