Failure to Administer Ordered Insulin Due to Pharmacy Non-Delivery
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with multiple diagnoses, including a right femur fracture, metabolic encephalopathy, type 2 diabetes mellitus, and atrial fibrillation. According to the clinical record, there was a physician's order for the resident to receive Xultophy insulin subcutaneously at bedtime for diabetes management. The Medication Administration Record (MAR) indicated that this medication was not administered as ordered on four consecutive days. During an interview, the Director of Nursing confirmed that the insulin was not given because the pharmacy did not provide the medication. This failure to administer the prescribed medication was in direct violation of the facility's policy, which requires that physician orders be followed and carried out by authorized personnel to ensure residents receive all ordered medications and treatments in a timely manner.