Failure to Administer Diabetes Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications for diabetes management were administered as ordered by the physician for one resident. The resident, who had diagnoses including diabetes mellitus, hypertension, and heart failure, was admitted with physician orders for Insulin Lispro to be given in the morning and at night, as well as Humalog sliding scale insulin to be administered based on blood sugar readings at multiple times throughout the day. Review of the Medication Administration Record showed that Insulin Lispro was not given in the morning and Humalog sliding scale insulin was not administered at lunch on a specific date. The resident's care plan indicated that staff should administer medications as ordered, and facility policy required medications to be administered according to physician orders. The Director of Nursing Services confirmed that the insulin doses were missed as documented.