Inaccurate Insulin Administration Documentation
Penalty
Summary
The facility failed to accurately document the administration of insulin for one resident with diabetes, chronic kidney disease, and congestive heart failure. The resident had physician orders specifying that all insulin should be held if fasting blood sugar was 200 or below. Despite this, the Medication Administration Records (MAR) for April and May indicated that insulin was documented as administered on multiple occasions when the resident's blood sugar was below the specified threshold. Interviews with the resident, nursing staff, and the Director of Nursing confirmed that the resident was highly involved in their insulin management and would not allow insulin to be administered if their blood sugar was below 200. Nurses, including the one who documented the administrations, acknowledged that insulin should not have been documented as given when it was not, and that the documentation was inaccurate. A review of the facility's charting and documentation policy indicated that all documentation should be objective, complete, and accurate. However, there was no clarifying information in the nursing progress notes regarding whether insulin was actually administered or held on the dates in question, leading to a failure to maintain accurate medical records in accordance with professional standards.