Failure to Update Insulin Order Results in Missed Dosage Change
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus, diabetic neuropathy, and bilateral leg amputations did not receive the correct insulin dosage as ordered. The Nurse Practitioner (NP) reviewed the resident's labs and provided a new order to increase the evening dose of Admelog insulin from 14 units to 18 units. However, the physician's order was not updated in the resident's record to reflect this change. As a result, the Medication Administration Record (MAR) showed that the resident continued to receive 14 units of Admelog on two consecutive evenings instead of the newly ordered 18 units. The resident's blood sugar levels remained significantly elevated during this period, with documented readings of 420 mg/dL and 400 mg/dL. The NP confirmed her expectation that the increased dose should have been administered, and the Director of Nursing Services acknowledged that the order was not updated until the surveyor brought it to her attention. This failure resulted in the resident missing two doses of the correct insulin dosage as ordered by the NP.