Failure to Follow Insulin Administration Standards and Physician Notification Protocols
Penalty
Summary
Staff failed to follow professional standards of practice in the administration and management of insulin for two residents. For one resident with diabetes mellitus, physician orders required blood sugar checks three times daily and notification of the primary care provider if blood glucose exceeded 400 mg/dl or dropped below 70 mg/dl. Despite multiple documented instances where the resident's blood sugar readings were above 400 mg/dl, there was no documentation that staff notified the physician as required by the orders. Additionally, during observations of insulin administration for another resident, a nurse was seen priming an insulin pen horizontally, contrary to the manufacturer's instructions, which specify that the pen should be primed with the needle pointing up to ensure accurate dosing. The facility's policy and administrative nurse confirmed that staff are expected to follow these procedures and notify physicians of out-of-range blood sugar levels.