Failure to Administer Insulin and Perform Blood Glucose Monitoring as Ordered
Penalty
Summary
The facility failed to ensure that a resident received medications as prescribed, specifically regarding the administration of insulin and blood glucose monitoring. On the morning in question, the resident refused a fasting blood sugar (FSBS) check at 6 a.m., and as a result, did not receive the scheduled dose of Novolin N FlexPen insulin, which was to be administered unless the blood sugar was below 100. The Medication Administration Record (MAR) indicated the FSBS was refused and the insulin was not given, with documentation codes reflecting these actions. The resident had a complex medical history, including type 2 diabetes mellitus, hypertension, gastrotomy, and chronic kidney disease. The resident's records indicated inconsistent capacity to make healthcare decisions, and the Minimum Data Set (MDS) noted that the resident sometimes understood and was sometimes understood. Despite the refusal of the FSBS, previous blood sugar readings at 12:04 a.m. and 11:56 a.m. were 121 and 109, respectively, both above the threshold for holding insulin. Facility policy required medications to be administered according to physician orders and blood glucose testing to be performed as ordered. Later that day, the resident experienced a significant change in condition, including hypotension and an elevated blood sugar level of 379, leading to hospital transfer. The Assistant Director of Nursing (ADON) confirmed that staff should have obtained another blood sugar check at 6 a.m. to ensure accurate assessment and appropriate insulin administration, as the available blood sugar readings did not meet the criteria for withholding the medication.