Failure to Notify Physician of Missed Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident's physician was notified when sliding scale insulin was not administered as ordered. The resident, who had a diagnosis of diabetes mellitus and was dependent on renal dialysis, had physician orders for sliding scale insulin to be given three times daily based on specific blood glucose ranges. Review of the Medication Administration Record (MAR) for the month showed multiple instances where the 5 PM dose of sliding scale insulin was not provided, either due to the resident being out of the facility or with no documentation explaining the omission. On several dates, the MAR was left blank, and there was no evidence that the physician was informed of these missed doses. Further review of the resident's progress notes for the same period did not reveal any documentation that the provider had been notified about the missed insulin administrations. Interviews with the Director of Nursing (DON) confirmed that the expectation was for the resident's blood sugar to be checked and insulin administered after returning from dialysis, and that not administering the insulin constituted a significant medication error. The DON also confirmed that documentation of provider notification could not be located. Facility policy required that the attending physician and responsible party be notified of medication errors, but this was not followed in this case.