Failure to Document Sliding Scale Insulin Administration
Penalty
Summary
The facility failed to document the amount of sliding scale insulin administered to a resident with type 2 diabetes mellitus who was receiving Humalog insulin according to physician orders. Review of the medication administration records for the resident over multiple date ranges showed that, although blood sugar readings were recorded, there was no documentation of the specific number of insulin units given for blood sugars above 100, as required by the sliding scale orders. The physician's orders provided clear dosing instructions based on blood sugar ranges, but the records did not reflect the actual doses administered. Interviews with the DON and an LPN revealed that staff followed the sliding scale orders, but the electronic health record system may not have provided an option to document the exact amount of insulin administered. The LPN stated that they sometimes entered this information in a note, but acknowledged the importance of having this documentation available for ongoing insulin treatment, interventions, and emergencies. The facility was unable to provide documentation of the insulin doses administered for the dates reviewed.