Failure to Administer and Document Insulin and Blood Glucose Monitoring
Penalty
Summary
The facility failed to administer prescribed insulin doses and monitor blood glucose levels as ordered for five out of seven sampled residents with diabetes mellitus type 2. For each of these residents, physician orders specified insulin administration according to a sliding scale and required regular blood glucose monitoring. On a specific date, the Medication Administration Records (MARs) for all five residents showed no documentation of insulin administration or blood glucose checks for the scheduled early morning dose. Additionally, there was no documentation in the nursing progress notes explaining the missed doses, nor any evidence that the attending physicians were notified of these omissions. The affected residents had complex medical histories, including conditions such as hemiplegia, chronic kidney disease, heart failure, osteomyelitis, and recent fractures, in addition to diabetes. Their care plans consistently included interventions to administer diabetes medications as ordered, monitor for side effects and effectiveness, and report abnormal findings to the physician. Despite these care plan directives, the required insulin and blood glucose monitoring were not performed or documented for the specified dose. Interviews with facility staff confirmed that there was no licensed nurse present in the skilled unit during the relevant time frame, resulting in the omission of scheduled medications for multiple residents. The Interim Director of Nursing acknowledged the blank MARs and confirmed that staff should have documented the reason for any missed doses in the progress notes. Facility policies reviewed by surveyors required medications to be administered as prescribed, all services to be documented, and any medication omissions to be recorded as errors.