Failure to Transcribe and Implement Sliding Scale Insulin Order for Diabetic Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services to ensure the accurate administration of medication for a resident with multiple complex diagnoses, including type 2 diabetes, coronary artery disease, hypertension, COPD, diabetic foot ulcers with gangrene, cellulitis, and sepsis status post below-knee amputation. Upon admission from the hospital, the resident's discharge summary included orders for scheduled insulin (Lantus and lispro) and a sliding scale insulin regimen, along with a recommendation to monitor blood sugars closely. However, the sliding scale insulin order and the recommendation for frequent blood glucose monitoring were not transcribed into the resident's Medication Administration Record (MAR), and only once-daily blood glucose checks were ordered and performed. Staff interviews and record reviews revealed that the facility's process for transcribing hospital discharge orders was not followed thoroughly. The Director of Nursing (DON) and nursing staff indicated that orders are transcribed from the discharge summary and reviewed by the provider and pharmacy, but the sliding scale insulin order was omitted. Nursing staff were unaware that the sliding scale order was missing, and there was confusion regarding the frequency of blood glucose monitoring. The facility's policies required verification and clarification of transfer orders, but this was not done for the sliding scale insulin order. Further, the pharmacy did not identify the missing sliding scale order during their review, as they only check for discrepancies if a medication appears to be off. The DON acknowledged that the sliding scale should have been clarified and included in the orders, and that there was no process in place for a second nurse to double-check the transcription of admission orders. As a result, the resident did not receive blood glucose monitoring or insulin administration according to the hospital discharge instructions.