Failure to Notify Resident and Representative of Changes in Insulin Orders
Penalty
Summary
The facility failed to inform a resident with diabetes mellitus and her responsible party in advance about changes made to her physician orders regarding insulin dosing and blood glucose monitoring. Upon re-admission from the hospital, the resident's orders were changed by the nurse practitioner from a sliding scale insulin regimen with blood glucose checks four times daily to a reduced frequency of two times daily and discontinuation of the sliding scale insulin. There was no documented evidence that either the resident or her responsible party was notified of these changes, as required by facility policy and regulatory standards. The responsible party only became aware of the changes several days after admission when the resident reported not receiving her insulin shots. Upon inquiry, the responsible party learned of the order changes from nursing staff and subsequently had the original orders reinstated after discussing with the nurse practitioner. Interviews with staff, including the charge nurse and DON, confirmed that notification of such changes is expected practice, but in this instance, the notification was missed. Facility policy also requires prompt notification of residents and their representatives regarding changes in care or treatment.