Failure to Follow Physician's Orders for Insulin Administration
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Facility staff failed to follow physician's orders for two residents with diabetes mellitus and other significant diagnoses. For one resident, staff administered 24 units of insulin (Lispro) subcutaneously three times a day even when the resident's blood glucose was below 150 mg/dl, contrary to the physician's order to hold the medication under those circumstances or if the resident had not eaten. For another resident, staff administered insulin based on a sliding scale when the blood glucose was above 351 mg/dl but did not notify the physician as required by the order. These failures were confirmed by review of clinical records and staff interview.