Failure to Ensure Proper Insulin Pump Management and Carbohydrate Counting
Penalty
Summary
The facility failed to ensure that a resident with type 1 diabetes mellitus, spastic quadriplegic cerebral palsy, and a recent right humerus fracture received proper assistance with insulin pump management and carbohydrate counting as ordered by the physician. The resident was dependent on staff for all activities of daily living, including eating, and was unable to independently calculate or enter carbohydrate counts into the insulin pump due to physical limitations. Despite physician orders specifying that staff should assist with carbohydrate counts and insulin pump operation, there was no evidence in the medical administration records that this assistance was consistently provided across multiple meals and days. Staff interviews revealed a lack of knowledge and training regarding the resident's insulin pump and carbohydrate counting. Several nurses and LPNs admitted they were unfamiliar with the insulin pump's operation, did not know they were responsible for providing carbohydrate counts, or relied on the resident to guide them through the process. Documentation showed that staff did not consistently record carbohydrate counts or verify that insulin boluses were administered as ordered. Additionally, there was a transcription error regarding insulin dosage, and the nurse involved was unaware of the correct dose to administer, further contributing to medication errors. The resident's care plan did not reflect current physician orders related to carbohydrate counting and insulin pump management. The facility did not provide staff education on the use, care, or maintenance of the insulin pump, nor did it assess the resident for self-administration of medication. The lack of updated care plans, staff training, and proper documentation led to significant medication errors, including missed or incorrect insulin administration and inadequate monitoring of blood glucose levels.