Failure to Administer Insulin According to Physician Orders and Manufacturer Guidelines
Penalty
Summary
The facility failed to follow physician orders and manufacturer instructions for the administration of both short-acting and long-acting insulin for a resident with diabetes. The resident, who was cognitively intact as indicated by a BIMS score of 15 out of 15, reported that short-acting insulin doses were often administered late, sometimes after meals had already been consumed. Documentation review confirmed that on multiple occasions, short-acting insulin (Insulin Lispro) was given significantly earlier or later than the scheduled mealtimes, contrary to the manufacturer's instructions that it should be administered within 15 minutes before a meal or immediately after eating. Specific instances included insulin being given more than an hour before breakfast or after dinner, and in one case, the resident had already eaten dessert before receiving insulin. Further review of medication administration records revealed that long-acting insulin (Insulin Glargine-yfgn) was also administered more than an hour after the ordered time on several occasions. The facility's own policy required medications to be administered within 60 minutes of the scheduled time, with those ordered before or after meals to be given based on mealtimes. Despite these policies and clear manufacturer guidelines, the timing of insulin administration did not consistently align with physician orders or best practices for diabetes management. Interviews with facility staff, including the Director of Nursing, confirmed that these deviations occurred and that the late administration of medications was not reported to nursing leadership or the prescribing physician. As a result, the physician was not made aware of the missed or late doses, and no immediate corrective action was documented at the time of the events. The findings were based on interviews, record reviews, and direct statements from the resident involved.