Failure to Administer Insulin Due to Lack of Staff Access
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors when staff did not administer insulin as ordered for three residents with diabetes. The residents had physician orders for specific types and dosages of insulin, including scheduled and sliding scale doses, as well as orders for regular blood glucose monitoring. On the morning in question, documentation showed that blood sugar checks and insulin administrations were not completed or recorded for these residents. Progress notes did not provide explanations for the missed doses, and residents reported not receiving their insulin or having their blood sugar checked. Interviews with the affected residents revealed that they were aware of the missed insulin doses and expressed concern about their blood sugar levels. One resident was observed to be flushed and worried, another reported not receiving insulin or having blood sugar checked, and a third appeared fatigued and unable to hold a conversation. All three residents stated that staff informed them the nurse on duty did not have access to administer insulin or check blood sugar levels. The Medication Administration Records (MARs) and progress notes corroborated the lack of documentation and administration for the scheduled insulin doses and blood glucose checks. Staff interviews confirmed that the nurse assigned to administer medications that morning did not have access to the electronic medical records (EMR) or the medication dispensing system, and was therefore unable to provide the required insulin. The nurse also reported having a broken hand, further limiting their ability to administer medications. Other staff members and facility leadership acknowledged that access to the medication system should have been provided prior to the start of the shift, and that residents should receive medications as ordered. The deficiency was further substantiated by the lack of care planning for medication management in some residents' records and the absence of communication to the physician regarding missed doses.