Failure to Administer Prescribed Insulin Upon Admission Due to Inadequate Medication Reconciliation
Penalty
Summary
Two residents were admitted to the facility and did not receive their necessary prescribed insulin medications upon admission. In the first case, the resident and their representative reported concerns that insulin was not administered as ordered, with the resident only receiving half of the normal dose after repeated requests. The resident's hospital discharge paperwork included orders to stop insulin, which led the admitting nurse to withhold the medication despite the resident's statements and a filed grievance. There was no documentation that the discharge medication list was reviewed or reconciled with a provider upon admission, and blood glucose monitoring was not initiated until two days after admission, at which point the resident's blood glucose was elevated. In the second case, another resident with a history of diabetes was admitted without clear documentation of insulin orders in the hospital paperwork, though the discharge summary indicated the resident was on insulin. The resident's representative informed the admitting nurse of the need for insulin, but the resident went a day or more without receiving it. Blood glucose checks were not performed until two days after admission, revealing significantly elevated levels. Insulin orders were not entered until two days post-admission, and there was no evidence that the medication reconciliation was reviewed with a provider at the time of admission. Interviews with nursing staff and facility leadership revealed inconsistent practices regarding medication reconciliation and provider notification upon admission. The Director of Nursing confirmed that there was no documentation of provider review for the admission medications and acknowledged that nurses were expected to call the provider before entering orders. The facility lacked policies on medication reconciliation, diabetes management, or a standardized admission process, and the use of the admission checklist was inconsistent among staff. These actions and inactions resulted in residents not receiving necessary prescribed medications in a timely manner.