Failure to Manage Insulin Administration for Dialysis Residents
Penalty
Summary
Facility staff failed to identify and implement a plan to manage medications, specifically insulin, for residents receiving dialysis services. Facility policy required that care and treatment, including medication management, be consistent with professional standards, physician orders, and care plans, and that communication with outside providers be maintained to ensure safe, continuous care. However, for three residents with End Stage Renal Disease and diabetes who were receiving hemodialysis and insulin injections, staff documented that insulin doses scheduled during dialysis times were not administered, marking them as 'Out of Facility' (OF) on the Medication Administration Record (MAR). For each of these residents, the MARs showed repeated instances where scheduled insulin doses were omitted on dialysis days, with no evidence that the residents' practitioners were notified of the missed doses. Interviews with nursing staff and unit managers confirmed that staff were unaware of who was responsible for administering insulin while residents were at dialysis and that practitioners were not notified when insulin was not given. There was also no indication that the insulin regimens were modified to account for the dialysis schedule or missed doses. The residents involved had significant medical histories, including End Stage Renal Disease, diabetes, and other chronic conditions, and required varying levels of assistance with activities of daily living. Despite these needs and the facility's own policy requirements, the lack of communication with practitioners and failure to adjust medication administration for dialysis schedules resulted in a deficiency in providing safe and appropriate dialysis care and services.