Failure to Implement Diabetic Management and Insulin Administration Protocols
Penalty
Summary
The facility failed to follow its own policy and procedure for diabetic management and insulin administration for a resident diagnosed with type 2 diabetes mellitus, chronic kidney disease, and quadriplegia. The resident was admitted and readmitted to the facility with orders for diabetes medications, including oral medication and insulin, but there were no consistent orders for blood sugar (BS) monitoring or insulin coverage as indicated by the resident's condition. The care plan for the resident specified monitoring for signs and symptoms of hyperglycemia and regular BS checks, but these interventions were not implemented by the staff. Licensed staff assigned to the resident were not aware of the resident's diabetes diagnosis and did not monitor BS levels or observe for symptoms of hyperglycemia or hypoglycemia. The resident's primary care provider (PCP) was not informed that there were no orders for BS monitoring or insulin coverage, and the PCP was unaware that BS checks were not performed for an extended period. The Medication Administration Record showed that insulin was administered inconsistently, and there were gaps in BS monitoring, particularly from one date to another, during which no BS checks were documented. As a result of these failures, the resident experienced a significant change in condition, presenting with high BS that could not be registered on the glucometer, altered level of consciousness, tachypnea, oxygen desaturation, and hypotension. The resident was transferred to a general acute care hospital, where a critically high blood glucose level was recorded, and the resident was diagnosed with diabetic ketoacidosis with coma, requiring intubation and intensive insulin therapy. Interviews with facility staff, including the RN Supervisor and DON, confirmed that the facility did not implement the care plan or ensure appropriate monitoring and treatment for the resident's diabetes.