Failure to Administer Insulin and Monitor Blood Glucose Leads to Resident Harm
Penalty
Summary
A 65-year-old resident with multiple complex medical conditions, including diabetes mellitus, cerebral infarction, hypertension, hemiplegia, chronic myelogenous leukemia, anemia, drug-induced polyneuropathy, atrial fibrillation, dysphagia, and a gastrostomy tube, was admitted to the facility. The resident had a physician's order for Glargine (insulin) to be administered every 12 hours for diabetes management. However, Glargine was not administered for three consecutive days at several scheduled times. Documentation indicated that the medication was not given due to new admission and unavailability, but there was no evidence that the physician or pharmacist was notified about the missed doses. Additionally, the facility failed to use the emergency medication kit to obtain the insulin, and staff did not seek assistance when unsure how to proceed. The facility also failed to ensure proper medication administration practices. When the resident's prescribed Glargine was not available, a nurse administered insulin from another resident's supply, which was not properly labeled for the intended resident. This action was contrary to facility policy, which prohibits borrowing medications between residents. Furthermore, the order for finger stick blood sugar (FSBS) monitoring was not clarified with the physician, and the correct monitoring frequency was not established. As a result, no blood glucose monitoring was performed during the resident's stay, and the need for such monitoring was not recognized by the nursing staff. Due to these failures, the resident experienced a critically high blood glucose level (593 mg/dL), which was identified through abnormal lab results. The physician was notified only after this result, and the resident was subsequently transferred to an acute care hospital for evaluation and treatment of uncontrolled diabetes. The resident ultimately died following the transfer. The facility's policies and procedures for medication administration, medication procurement, and diabetes management were not followed, and staff interviews revealed a lack of knowledge and experience in handling new admissions, medication errors, and diabetes care.