Incomplete and Inaccurate Documentation of Insulin Administration Parameters
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurately documented, specifically regarding the parameters for holding insulin administration. The resident, who had diagnoses including Type II diabetes and dementia with severe cognitive impairment, had physician orders and MARs that inconsistently documented the blood glucose (BG) threshold for holding Novolog insulin. The physician order and MAR initially stated to hold insulin if BG was less than 200, but nursing staff and the nurse practitioner indicated that the correct threshold should have been 100. A nurse made a typographical error when entering the order into the electronic record, and this discrepancy was not identified or corrected in a timely manner. Despite the error in documentation, nursing staff reported that they consistently held the insulin if the resident's BG was less than 100, following standard nursing judgment rather than the incorrect written order. The facility's policy required that each resident's medical record contain an accurate and complete representation of the resident's care, but the error in the electronic record and MAR resulted in inaccurate documentation of the resident's insulin administration parameters.