Inaccurate Medical Record Documentation for Insulin Administration
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident with multiple diagnoses, including COPD, dementia, neuromuscular dysfunction of the bladder, hypertension, Type II diabetes with diabetic polyneuropathy, major depressive disorder, and carpal tunnel syndrome. The resident was cognitively intact according to the most recent assessment. A physician order specified that insulin lispro should be administered before meals only if the resident's blood sugar was 150 or higher, with instructions to hold the medication if the blood sugar was below this threshold. Review of the Medication Administration Records (MAR) over several months revealed repeated documentation by an LPN that insulin was administered even when the resident's blood sugar was less than 150, contrary to the physician's order. Upon interview, the LPN confirmed that the insulin was not actually administered as documented and admitted to being unfamiliar with how to document when the blood sugar was outside the prescribed parameters. This resulted in inaccurate medical records for the resident.