Failure to Follow Physician Orders for Diabetic Care
Penalty
Summary
The facility failed to ensure that a resident with multiple diagnoses, including Type II diabetes, received care in accordance with professional standards by not following physician orders for diabetic medication management. Record review showed that the resident had specific physician orders for the administration of Insulin Glargine and for the use of Insta-Glucose when blood glucose levels fell below 70 mg/dL. Despite these orders, documentation revealed that on several occasions when the resident's blood glucose was below 70 mg/dL, staff did not administer Insta-Glucose as directed by the physician. Interviews with facility staff, including the DON, Administrator, and nurses, confirmed that the expectation was to administer Insta-Glucose per physician order when the resident's blood sugar was low. However, some nursing staff reported giving other forms of sugar, such as cookies, candy, or juice, instead of following the specific order for Insta-Glucose. The care plan for the resident also indicated monitoring and reporting abnormal blood glucose findings, but the prescribed intervention was not consistently implemented as ordered.