Failure to Notify Practitioners of Omitted Insulin Doses During Dialysis Absences
Penalty
Summary
Facility staff failed to notify residents' practitioners when scheduled insulin doses were omitted for three residents who were out of the facility receiving hemodialysis. Each of these residents had orders for insulin administration and required dialysis on specific days of the week. The Medication Administration Records (MARs) for these residents showed that insulin doses were marked as 'Out of Facility' (OF) on multiple occasions corresponding to their dialysis appointments, indicating the medication was not administered. Interviews with nursing staff, including agency nurses, LPNs, and the unit manager, revealed a lack of awareness regarding responsibility for insulin administration when residents were out for dialysis. Staff confirmed that practitioners should be notified when insulin is not given, but this notification did not occur for any of the affected residents. The facility's own policy required immediate notification to the resident, their representative, and the attending physician or delegate when there was a change in condition or treatment, including omitted medications. The residents involved had significant medical histories, including End Stage Renal Disease (ESRD), Diabetes Mellitus, and dependence on hemodialysis. Their cognitive status ranged from intact to moderately impaired, and they required varying levels of assistance with activities of daily living. Despite these complexities, the facility did not communicate missed insulin doses to practitioners, as confirmed by record review and staff interviews.