Failure to Follow Professional Standards in Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to follow professional standards of practice during insulin administration for four residents observed. Specifically, nurses were seen priming insulin pens incorrectly, either with the needle cap on or while holding the pen downward, contrary to facility policy which requires the needle cap to be off and the pen to be held upright during priming. These observations were confirmed by an administrative nurse who stated the expected procedure was not followed. Additionally, for one resident with Type 2 diabetes mellitus, staff did not notify the physician when blood glucose readings were outside the parameters set by the physician's order. The resident's medical record showed multiple instances of blood sugar levels below 100 mg/dL and above 450 mg/dL, but there was no documentation that the physician was informed as required by facility policy. This was acknowledged by an administrative nurse during interview.