Failure to Document and Administer Insulin per Physician Orders
Penalty
Summary
A deficiency was identified in the administration and documentation of insulin for a resident admitted with diagnoses including Critical Illness Myopathy and Type II Diabetes Mellitus with Hyperglycemia. The resident was cognitively intact and required supervision to limited assistance for activities of daily living. Physician orders specified a sliding scale for Insulin Lispro administration based on blood sugar (BS) readings, with instructions to notify the physician if BS was less than 70 or greater than 400. On one occasion, the resident had a BS reading of 570, but the amount of insulin administered was not documented, nor was there documentation that the physician was notified as required by the order. Additionally, there was a medication error where the resident did not receive insulin for a BS of 395, and the nurse involved stated she forgot to administer the medication and did not obtain the required blood sugar reading at lunch. Further review of the medical record and incident reports revealed that the nurse failed to follow the facility's Medication-Insulin Administration policy, which requires verification and documentation of insulin administration. The DON confirmed that the nurse did not provide the medication and failed to contact the physician as ordered. These actions and omissions resulted in a failure to provide appropriate treatment and care according to physician orders and facility policy.