Failure to Notify Physician of Missed or Late Insulin Administration
Penalty
Summary
Facility staff failed to notify the physician when a resident's prescribed 70/30 insulin was not administered or was administered late. The resident, who had a diagnosis of diabetes, had physician orders for Humulin 70/30 insulin to be given twice daily with blood sugar checks prior to administration. On multiple occasions, the insulin was either given late or not given at all, with blood sugar readings significantly above the normal range. Specifically, the insulin was administered several hours late on two occasions and was not administered at all on another occasion due to a delay in pharmacy delivery. Documentation on the Medication Administration Record (MAR) reflected these late or missed doses and the associated high blood sugar values. Nursing staff interviews revealed that the insulin was administered late due to the nurse's medication administration routine and that the physician was not notified when the insulin was missed or delayed. The DON confirmed that the expectation was for nurses to inform leadership and the physician if medications, particularly insulin, were not given on time. The physician stated he was not notified of the missed or late doses and would have expected immediate notification, especially given the resident's elevated blood sugar levels and the importance of timely insulin administration.