Failure to Administer Sliding Scale Insulin per Physician Order
Penalty
No penalty information released
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 follow physician orders regarding sliding scale insulin administration for one resident. Record review of the Medication Administration Record (MAR) showed that the resident had a physician order for Novolog insulin to be administered subcutaneously three times daily, with specific dosing based on blood glucose readings. On the morning of 6/3/2025, the resident's blood sugar was recorded as 148, which, according to the sliding scale order, required administration of 1 unit of insulin. However, the MAR indicated that zero units of insulin were given at that time. This finding was confirmed during an interview with the Director of Nursing, who acknowledged that the insulin was not administered as ordered.