Failure to Administer Insulin and Document Blood Glucose Checks as Ordered
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for one resident diagnosed with multiple conditions, including Type 2 Diabetes Mellitus. The resident had medical provider orders for Novolog insulin to be administered subcutaneously before meals and at bedtime, with specific dosing instructions based on a sliding scale and blood glucose checks. Review of the medication administration record (MAR) for August revealed that there was no documentation of blood glucose checks or administration, refusal, or holding of Novolog on several specified dates and times. The resident's care plan included interventions to administer medications as ordered and to monitor for signs and symptoms of hypoglycemia. During an interview, the DON was unable to provide evidence explaining the lack of documentation or administration of Novolog on the identified dates. The facility's policy required staff to check the MAR for orders and ensure any necessary tests, such as vital signs or blood glucose checks, were completed prior to medication administration. No further information or documentation was provided to the survey team to account for the missed treatments prior to the survey exit.