Failure to Administer Insulin as Ordered
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of diabetes mellitus did not receive insulin medications as ordered by the physician. Medical record review showed that the resident was cognitively intact and had physician orders for both long-acting and fast-acting insulin, including scheduled doses and sliding scale coverage. The Medication Administration Record (MAR) for March 2025 revealed multiple instances where the resident did not receive the prescribed insulin glargine and insulin lispro at scheduled times. There was no documentation in the nursing progress notes indicating that the resident refused these medications. During an interview, a registered nurse confirmed that missing initials on the MAR indicated the medications were not administered. The facility's policy required medications to be administered as ordered by the physician and in accordance with professional standards. The failure to administer insulin as ordered and the lack of documentation for missed doses or refusals led to the identified deficiency.