Failure to Administer Insulin as Ordered and Document Timely Administration
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes, severe obesity, dementia, and bilateral lower limb amputations did not consistently receive insulin as ordered. The resident was cognitively intact and required insulin administration per a physician's sliding scale and scheduled long-acting insulin at bedtime. Documentation and interviews revealed that the resident did not receive his evening insulin dose on one occasion, with the MAR indicating a refusal that the resident denied. Additionally, there were multiple instances where the evening long-acting insulin was administered outside the prescribed 7:00 P.M. to 11:00 P.M. window, including one dose given at 3:08 A.M. the following day. Staff interviews confirmed that nurses did not always check previous MAR entries to verify timely administration and sometimes delayed or omitted doses if the resident was not immediately available, even when the resident was present in the facility. The DON and Regional Director of Clinical Services acknowledged that insulin was administered outside the accepted timeframe and that documentation did not always reflect the actual time of administration. The facility's policy required medications to be given within one hour of the prescribed time unless otherwise specified, and the safety data sheet for the insulin emphasized the importance of consistent timing to avoid increased risk of hypoglycemia. The resident reported feeling ignored when requesting insulin and sometimes feeling lightheaded, suggesting possible effects from missed or delayed doses. Review of the MAR for the previous two months showed a pattern of late administration of the evening insulin dose on several dates. The facility failed to ensure the resident was free from significant medication errors by not administering insulin as ordered and not accurately documenting administration times.