Failure to Implement Hospital Discharge Orders for Insulin Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquisition, receipt, dispensing, and administration of all drugs and biologicals to meet the needs of a resident. Specifically, the facility did not carry out hospital discharge orders for insulin administration to control blood glucose for a resident with a diagnosis of uncontrolled type 2 diabetes mellitus. The resident was admitted with a history of diabetes, hypertension, urinary retention, and autistic disorder, and had clear hospital discharge instructions for insulin NPH Hum/Reg 70/30 to be administered subcutaneously before breakfast and dinner, as well as orders for blood glucose monitoring. Upon review, it was found that the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect any orders for insulin or blood sugar checks for the months following admission. Multiple staff interviews revealed a lack of awareness regarding the resident's need for insulin or glucose monitoring. The Director of Nursing (DON) acknowledged not entering the resident's orders into the electronic medical record and did not follow up to ensure hospital records were received. The nurse practitioner (NP) and medical director also failed to verify that the insulin orders were implemented, and the NP did not review the MAR/TAR during visits. The resident subsequently developed severe hyperglycemia and diabetic ketoacidosis (DKA), requiring transfer to the emergency room. The facility's own policies required thorough medication reconciliation upon admission, including review of hospital discharge summaries and communication with referring providers to resolve discrepancies. However, these procedures were not followed, resulting in the omission of critical insulin therapy and glucose monitoring for the resident. Staff interviews and documentation confirmed that the breakdown in communication and failure to implement discharge orders directly led to the resident's acute medical deterioration.