Failure to Administer Insulin According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for one resident with diabetes mellitus. According to facility policy, medications are to be administered at the correct time as ordered by an authorized licensed practitioner. Review of the clinical record for a resident with diabetes showed physician orders for Humulin, a long-acting insulin, to be administered once daily at 8:00 AM. However, the Medication Administration Record documented multiple instances where the insulin was administered late, with times ranging from over an hour to more than two hours past the scheduled time on several dates. Interviews with the resident confirmed that insulin administration and blood sugar checks were sometimes performed after meals. The DON stated that medications should be administered within one hour before or after the scheduled time, but was unable to provide a rationale for the late administration of Humulin. The deficiency was cited under state regulations for management and resident care policies.