Failure to Administer Insulin According to Physician Orders and Manufacturer Guidelines
Penalty
Summary
A deficiency occurred when a resident with a history of dementia and type 2 diabetes did not receive insulin according to physician orders. The resident was admitted with orders for blood glucose checks before meals and administration of sliding scale insulin based on those results. On one occasion, the assigned LVN failed to check the resident's blood glucose before dinner and, as a result, did not administer the prescribed insulin. The LVN later stated that she was occupied with a medical emergency involving another resident and was unable to perform the required blood glucose check and insulin administration as ordered. On a separate occasion, the same LVN administered rapid-acting insulin to the resident well before the scheduled dinner time, and the resident did not receive a meal or snack within the recommended timeframe after insulin administration. The insulin was given at approximately 4:08 p.m., but the resident did not receive his dinner tray until about 5:15 p.m., exceeding the recommended interval for providing food after rapid-acting insulin. Facility policy and manufacturer specifications require that a meal or substantial snack be provided within 15 minutes of administering rapid-acting insulin to prevent hypoglycemia. Observations and interviews confirmed that the resident was non-verbal, had significant cognitive impairment, and required assistance with feeding. Staff interviews revealed inconsistent knowledge and practices regarding the timing of blood glucose checks and insulin administration relative to meals. Documentation showed that the required procedures were not followed, resulting in significant medication errors for the resident.