Failure to Hold Insulin per Physician Parameters
Penalty
Summary
Facility staff failed to ensure that a resident was free from unnecessary medications, specifically regarding the administration of Lantus insulin. The resident, who had diagnoses including cerebral infarction, type 2 diabetes mellitus, and hypertension, was cognitively intact according to the most recent MDS assessment. The resident's care plan included diabetes management with medication as ordered by the physician. The physician's order for Lantus insulin specified that it should be held if the resident's blood sugar (BS) was less than 150. Review of the electronic medication administration records (eMAR) for February and March showed that the resident received Lantus insulin multiple times when their BS was below the ordered hold parameter of 150. Specific instances included administration with BS readings of 147, 129, 104, 128, 142, 131, and 117. The DON confirmed that the insulin should have been held according to the physician's parameters. Facility policy also required medications to be held when vital signs were outside prescribed parameters. No additional information was provided prior to the survey exit.