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F0658
D

Failure to Follow Physician's Orders for Insulin Administration and Nutritional Support

Woonsocket, Rhode Island Survey Completed on 08-05-2025

Penalty

No penalty information released
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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

The facility failed to ensure that services provided met professional standards of quality by not following physician's orders for a resident with diabetes mellitus. Specifically, there was a physician's order for Humalog insulin to be administered according to a sliding scale based on blood sugar readings. However, documentation was missing to show that the resident's blood sugar was obtained at two specified times, which was necessary to determine if insulin administration was required. Additionally, there was a physician's order for a high protein snack at bedtime for nutritional support, but the snack was not provided on two occasions, despite the items being available in the facility. During interviews, an LPN was unable to explain why the high protein snack was not given and could not provide evidence that blood sugar checks were performed as ordered. The President of Operations also confirmed that the required snack items were available and acknowledged the lack of documentation for the blood sugar checks. These findings indicate that the facility did not consistently follow physician's orders for medication administration and nutritional support for the resident.

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