Failure to Administer Ordered Insulin and Monitor Blood Glucose Leads to Resident Death
Penalty
Summary
The facility failed to provide ordered morning medications, including sliding scale insulin, and did not monitor blood glucose levels as ordered for a resident with type 1 diabetes, Parkinson's disease, and hypertensive heart disease with heart failure. The resident was admitted with a care plan that required administration of medications and blood sugar monitoring as ordered. On the night in question, there was no licensed nurse present on the skilled unit from 2 a.m. to 7 a.m. due to staff call-offs, and the scheduled 5 a.m. to 6:30 a.m. medications were not administered. Staffing records confirmed the absence of licensed nurses during this period, and interviews with staff indicated that multiple attempts to notify facility leadership about the staffing shortage went unanswered. Review of the resident's medication administration record showed no documentation of insulin administration or blood glucose monitoring for the scheduled morning dose. Nursing progress notes indicated the resident was sleeping and unable to receive medication, but there was no documentation of further attempts to administer medication, no blood sugar checks, and no physician notification. When the day shift nurse arrived, she was informed by a CNA that no licensed nurse had been present overnight, and she did not check the resident's blood sugar until the resident became unresponsive later that morning. The glucometer then displayed a reading of "HI," indicating critically high blood glucose. The resident was found unresponsive and was transferred to the emergency room, where hospital records indicated severe hyperglycemia, altered mental status, and a glucose reading greater than 650. The resident was admitted to the ICU, placed on comfort care, and subsequently passed away. The facility's policies required medications to be administered safely and as prescribed, and for care plans to describe services necessary to maintain the resident's well-being, but these were not followed in this instance.