Failure to Document Insulin Administration and Change of Condition
Penalty
Summary
A licensed vocational nurse failed to document the administration of insulin Aspart, 35 units, for a resident with diabetes mellitus on the Medication Administration Record (MAR) for a specified morning dose. The MAR review showed no indication that the insulin was administered as ordered, and the nurse did not record the medication administration. The nurse acknowledged the importance of following physician orders and documenting medication administration to ensure resident safety and to provide proof of care. The resident's care plan required insulin administration before meals, and the nurse did not implement this intervention as outlined. Additionally, the same resident experienced a change of condition (COC) involving agitation and a verbal altercation with a certified nursing assistant. Although an SBAR form documented the incident, there was no corresponding documentation in the nursing progress notes for the evening shift on the day of the event. Facility staff confirmed that documentation of COC should occur every shift for 72 hours following such incidents, as part of the nursing care plan. The lack of documentation meant that staff would not be aware of the resident's emotional and psychosocial status, potentially delaying necessary care. Facility policies and job descriptions reviewed indicated that licensed vocational nurses are responsible for implementing care plans, administering medications per physician orders, and documenting accurately and thoroughly. The facility's policies required prompt, complete, and factual documentation of resident conditions, changes, and all medication administrations. The failure to document both the insulin administration and the resident's change of condition was inconsistent with these requirements.