Failure to Maintain Emergency Insulin Supply Results in Missed Doses
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with type 2 diabetes, heart failure, and chronic kidney disease. Specifically, the facility did not maintain an emergency supply of Lispro (fast-acting insulin), resulting in the resident missing a scheduled bedtime dose and a scheduled morning dose of insulin. Documentation on the Medication Administration Record indicated that the insulin was unavailable and awaiting pharmacy fill, and the resident's blood sugar was recorded at 386 at the time the morning dose was missed. Nursing staff confirmed that the insulin was not available in the stat safe and had not been delivered by the pharmacy at the time it was needed. Record reviews and staff interviews revealed that the resident was severely cognitively impaired and required insulin injections as ordered by the provider. The facility's procedures required medications to be administered in accordance with orders and within required time frames, but these procedures were not followed in this instance. The absence of the required insulin and the failure to administer it as scheduled constituted a deficiency in pharmaceutical services, as the resident did not receive therapeutic doses of medication as ordered.