Failure to Administer Insulin and Monitor Blood Glucose as Ordered
Penalty
Summary
A review of facility policy, clinical records, and staff interviews revealed that the facility failed to administer medications as ordered by the physician for one resident. The resident, who was cognitively intact, independent with personal care, and had a diagnosis of diabetes, returned to the facility from the hospital with specific physician orders for insulin aspart (using a sliding scale and fixed doses before meals) and insulin glargine. On the day of return, there was no documented evidence that the resident's blood glucose was checked or that the prescribed insulin doses were administered. The resident reported not having their blood sugar checked and experiencing a headache, with their glucose monitor reading "HI." The physician was notified of the omitted insulin doses and blood glucose checks. The Director of Nursing confirmed that the resident's blood glucose should have been monitored and insulin administered as ordered, but this did not occur upon the resident's return from the hospital.