Failure to Administer Insulin per Physician Orders and Notify Physician When Withheld
Penalty
Summary
The facility failed to follow professional standards of practice for diabetes management for one resident. According to the clinical record, the resident had diagnoses including cerebral infarction and diabetes, and was assessed as having moderately impaired cognition. Physician orders specified that the resident was to receive insulin aspart 5 units subcutaneously four times daily. However, the Medication Administration Record (MAR) showed that multiple doses of insulin aspart were withheld on several occasions, with documented blood glucose levels ranging from 94 mg/dL to 118 mg/dL, and in one instance, no blood glucose was documented at all. There were no physician orders providing parameters for when insulin aspart could be held, and there was no documented evidence that the physician was notified when the insulin doses were withheld. Facility policy required that medications be administered according to physician orders and that the physician be contacted if there were concerns about the appropriateness of a medication or if it was withheld. The failure to administer insulin as ordered and to notify the physician of withheld doses constituted a deficiency in following professional standards and facility policy.