Failure to Assess and Administer Insulin for Diabetic Resident on Admission
Penalty
Summary
A deficiency occurred when facility staff failed to assess, implement interventions, and communicate with the provider in response to a resident's rising blood sugar levels following admission. The resident, with a known history of type 1 diabetes requiring multiple daily insulin doses, was admitted after a hospitalization for heart failure. Upon admission, staff did not perform a comprehensive assessment, including checking the resident's heart, lungs, or swelling, nor did they provide a meal or check her blood sugar until later in the day. When blood glucose checks were eventually performed, results were elevated (245 mg/dL and 324 mg/dL), and the resident requested insulin, but staff reported there was no order for insulin and did not administer it. Throughout the evening and overnight, the resident continued to experience symptoms of hyperglycemia, including cotton mouth, fruity breath, dizziness, and unsteadiness. Despite these symptoms and repeated elevated blood sugar readings, nursing staff did not contact the provider or take further action to obtain or administer insulin. The following morning, critical lab values were reported, and the resident was transferred to the emergency room, where her blood glucose was found to be 701 mg/dL, and she was diagnosed with diabetic ketoacidosis (DKA) and acute kidney injury. Interviews and record reviews revealed that the hospital had provided discharge orders for long-acting and sliding scale insulin, but these were not entered into the facility's system or administered. Multiple staff members, including RNs and LPNs, were aware of the resident's diabetes diagnosis but did not verify or ensure insulin orders were in place, nor did they utilize the emergency medication kit or escalate the issue to the provider in a timely manner. Further investigation showed breakdowns in the admission process, including lack of communication between staff, incomplete review and confirmation of hospital discharge orders, and failure to follow the facility's admission checklist. Staff interviews indicated confusion over responsibilities, lack of training on emergency medication access, and failure to recognize the urgency of the resident's condition. The pharmacy also did not enter the insulin orders, and staff did not follow up to resolve the discrepancy. As a result, the resident did not receive necessary insulin, leading to a critical medical emergency.