Failure to Follow Physician Orders for Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for the administration of sliding scale insulin for one resident. The resident had a physician order specifying the amount of insulin to be administered based on finger stick blood sugar (FSBS) results, with instructions to call the physician if the FSBS exceeded a certain threshold. On one occasion, the resident's FSBS was recorded as 563, but staff administered 15 units of insulin without contacting the physician as required by the order. On another occasion, the resident's FSBS was 288, but only 3 units of insulin were administered instead of the 6 units specified in the order. These discrepancies were confirmed through record review and interview with the Assistant Director of Nursing. The clinical record did not contain evidence that the physician was notified or that a new order was obtained for insulin administration when the FSBS exceeded the ordered range, and the insulin doses given did not always match the sliding scale instructions.