Failure to Maintain Accurate Medical Records for Insulin Administration
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for one resident with type two diabetes mellitus who was cognitively intact and required daily insulin. Review of the resident's Medication Administration Record (MAR) for June showed that on two specific dates, the administration of ordered insulin glargine was not documented, with the MAR left blank and lacking nurse initials or chart codes. The resident maintained a personal notebook, noting that insulin was not administered on those dates, and confirmed in an interview that she did not refuse the medication but was not offered it by nursing staff. Further investigation revealed that the Director of Nursing (DON) had no evidence that the insulin was administered as ordered on the identified dates. An LPN confirmed that she did not administer the insulin on those days due to workload and did not document a refusal, verifying that refusals should be recorded in the MAR at the time they occur. Additionally, the MAR was altered after the surveyor's inquiry, with an entry added to indicate a refusal on one of the dates, but no change made for the other. The original MARs were void of required documentation, and the alteration occurred after the issue was brought to the facility's attention.