Failure to Verify Insulin Dosage and Document Blood Glucose Levels
Penalty
Summary
The facility failed to implement its policy and procedures regarding insulin administration for a resident with multiple diagnoses, including diabetes mellitus, hypertension, hemiplegia, and epilepsy. The physician's order for Insulin Glargine was incorrectly written as 15 milliliters (ml) instead of the appropriate unit-based dosage, and this error was not identified or clarified by nursing staff prior to administration. The Medication Administration Record (MAR) indicated that the incorrect dosage was documented as being administered on multiple occasions, and the order was not verified with the physician as required by facility policy. Additionally, the facility did not ensure that the resident's blood sugar levels were consistently documented in the electronic medical record. There were several dates where blood sugar results were missing, despite the requirement to check and record these levels to guide insulin administration. The lack of documentation meant that it was unclear whether blood glucose was monitored as ordered, which is necessary to safely administer insulin and prevent adverse outcomes. Interviews with nursing staff and the Director of Nursing confirmed that the insulin order was not written in accordance with standard practice, and that the error could have resulted in a significant overdose if administered as written. The facility's policies required verification of insulin dosage and documentation of blood glucose results, but these procedures were not followed, leading to the identified deficiencies.