Failure to Follow Insulin Administration Orders
Penalty
Summary
Nursing staff failed to follow physician orders regarding insulin administration for a resident with diabetes, pancreatectomy, and Hodgkin's lymphoma. The physician's order specified that Lispro insulin should be held if the resident's blood sugar (BS) was below 270 mg/dL. Despite this, the Medication Administration Record (MAR) showed that the resident received 3 units of Lispro insulin at two separate times when their BS was 257 mg/dL and 157 mg/dL, both below the threshold set by the physician. The facility's policy on hypoglycemia management requires nursing staff to notify the physician if hypoglycemia signs are not resolved by protocol. However, there is no indication in the report that the physician was notified or that the protocol was followed in response to the administration of insulin when it should have been held. The Director of Nursing confirmed that the insulin was administered contrary to the physician's order on the specified dates and times.