Failure to Perform Pre-Meal Blood Sugar Checks and Proper Insulin Pen Priming
Penalty
Summary
The facility failed to ensure that blood sugar assessments were performed prior to breakfast and that insulin pens were properly primed before administration for two residents with diabetes. In both observed cases, residents had already consumed their entire breakfast before LPNs assessed their blood sugar levels and administered insulin. For one resident, the LPN administered a total of nine units of Humalog insulin (six units routine and three units per sliding scale) after breakfast, without priming the insulin pen. The LPN stated she only primed new pens and had not been priming the pen for ongoing use, despite working with all residents on all floors. The resident's care plan and physician orders required blood sugar checks and insulin administration in relation to meals, and the facility policy specified that insulin pens should be primed prior to each use. A second resident, also with diabetes, had their blood sugar checked and received both Humalog and glargine insulin after finishing breakfast. The LPN confirmed the timing of the blood sugar assessment and insulin administration occurred post-meal. The Director of Nursing confirmed that blood sugar assessments were to be completed prior to meals. Facility policy required insulin pens to be primed before each use, but this was not followed. These failures affected two observed residents and had the potential to impact an additional 24 residents identified as requiring pre-meal blood sugar assessments and/or insulin via pen.