Failure to Follow Insulin Administration Orders and Blood Sugar Monitoring Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs in the administration and monitoring of insulin for three residents. For one resident with muscular dystrophy and diabetes, insulin was administered even when blood sugar levels were below the ordered threshold, and there was no documentation explaining the rationale for giving insulin outside of the prescribed parameters. Another resident with type 1 diabetes had multiple instances of extremely high blood sugar readings, but there was no documentation that the provider was notified as required by the physician's order. The facility's staff confirmed that there was no record of provider notification or new orders in response to these abnormal results. Additionally, a third resident with type 2 diabetes did not have blood sugar assessments completed on several days, despite documentation on the medication administration record indicating otherwise. There was no evidence in the electronic medical record that the assessments were performed or any rationale provided for missing the assessments. The facility's policy requires that vital signs be obtained and recorded per physician orders and that medications be held if parameters are not met, but these procedures were not followed in the cases reviewed.