Failure to Transcribe and Implement Blood Glucose Monitoring and Insulin Orders on Admission
Penalty
Summary
The facility failed to ensure that blood glucose monitoring was performed three times daily and that Levemir insulin was accurately transcribed and administered upon admission for one resident. Upon review, it was found that the resident was admitted with orders from a general acute care hospital for blood glucose checks three times a day and Levemir insulin to be given at bedtime as needed for elevated blood sugar. However, these orders were not entered into the facility's system at the time of admission, resulting in the resident not having her blood sugar checked throughout the day as indicated and not receiving long-acting insulin for five days after admission. The resident involved had a history of type 2 diabetes mellitus, moderate cognitive impairment, and required significant assistance with daily activities. The Director of Nursing confirmed during an interview and record review that the admitting nurse missed entering the orders for blood sugar checks and insulin, which were only added several days later. Facility policy required that physician admission orders, including medication and routine care orders, be provided and implemented at or prior to admission, but this process was not followed in this case.