Delayed Insulin Administration for High Blood Sugar
Penalty
Summary
A resident with type 2 diabetes, who was admitted to the facility and had intact cognition, experienced a significant delay in receiving appropriate treatment for a high blood sugar episode. On the evening in question, the resident's blood sugar was measured at 420 mg/dl at 9:00 PM. The resident requested insulin, but the nurse on duty stated she could not administer additional insulin without a physician's order. The nurse attempted to contact the on-call health care provider but did not receive a response for several hours. During this period, the resident continued to experience elevated blood sugar levels, with subsequent readings remaining high. The nurse and supervisor informed the resident that they were waiting for a response from the provider and could not administer more insulin due to the lack of specific orders and the risk of hypoglycemia. The resident did not receive the necessary insulin to address the high blood sugar until approximately 2:00 AM, about five hours after the initial report of the elevated level. Facility records and interviews confirmed that the process for escalating care in the event of a delayed provider response was not effectively followed. Both the DON and another RN indicated that a timely response from a provider should occur within 30 minutes to an hour, and that further steps could have been taken to contact another provider or escalate the situation. Facility policy also required timely provider response and escalation if needed, but these protocols were not adhered to, resulting in a prolonged period before the resident received appropriate treatment.