Failure to Administer Insulin as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a history of type 2 diabetes mellitus, cerebral infarction, and long-term insulin use did not receive their prescribed insulin glargine as ordered by the physician. The resident, who had severe cognitive impairment and required significant assistance with daily activities, had a physician's order for insulin glargine to be administered at bedtime if their blood sugar was not less than 100 mg/dL. On the date in question, the resident's blood sugar was recorded at 100 mg/dL, which was within the parameters for administration, but the insulin was not given. Interviews with nursing staff revealed that the omission was due to the nurse overlooking the parameters of the order and not reading it in its entirety. Both the registered nurse and the assistant director of nursing confirmed that the medication should have been administered according to the physician's order and facility policy, which requires medications to be given as prescribed. The facility's policy also emphasizes the importance of administering medications in a safe and timely manner, in accordance with prescriber orders.