Failure to Document Insulin Administration per Physician Order
Penalty
Summary
The facility failed to accurately document the administration of insulin lispro for one resident with diabetes and severe cognitive impairment. According to physician orders, the resident was to receive insulin lispro based on a sliding scale whenever blood sugar readings exceeded 200, with blood sugars checked three times daily. Review of the Medication Administration Record (MAR) for the specified period showed multiple instances where the resident's blood sugar was above 200, but there was no documentation that insulin lispro was administered as required. There was also no documentation of refusal or any rationale for not administering the insulin. Interviews with nursing staff and facility management confirmed that insulin administration should be documented at the time of administration, and that the resident did not refuse insulin. The DON acknowledged that the MAR was inaccurate and that the physician's order had been transcribed incorrectly as a PRN order, which failed to alert nurses to administer the insulin as scheduled. Subsequent statements from nursing staff indicated that insulin had been administered on the required occasions, but documentation was omitted.