Failure to Administer Insulin as Ordered
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus did not receive her ordered insulin glargine on two separate occasions, as documented in the Medication Administration Record (MAR) and confirmed by interviews and record review. The resident was cognitively intact, used insulin daily, and had no care plan addressing insulin administration despite her known selectivity regarding which nurse administered her medication. On the dates in question, the MAR was left blank for the insulin administration, and there was no documentation of refusal or nurse initials. The resident's blood glucose levels were elevated on those days, and she kept a personal notebook recording missed doses, which matched the MAR omissions. Interviews with nursing staff and administration revealed that the resident did not refuse her insulin on the identified dates; rather, she was not offered the medication, and no alternative approaches were attempted to ensure she received it as ordered. The LPN assigned to the resident did not administer the insulin due to workload and inability to cover for the nurse the resident did not trust. The DON confirmed there was no evidence the insulin was administered and no care plan was in place to address the resident's preferences or ensure consistent administration. Facility policies required medications to be administered as ordered and within specified time frames, which was not followed in this case.