Insulin Administered to Unresponsive Resident Without Emergency Response
Penalty
Summary
The facility failed to provide care in accordance with professional standards for medication administration during an emergency when a resident was found unresponsive and subsequently administered insulin. The resident, who had a history of Type 2 Diabetes Mellitus, epilepsy, seizures, unsteadiness, and schizoaffective disorder, was found unresponsive at 5:30am with a blood glucose level of 290 mg/dL. The nurse on duty documented administering both a scheduled dose and a sliding scale dose of Humalog insulin to the unresponsive resident before initiating emergency procedures such as calling a code, 911, or notifying a physician. The nurse's documentation was inconsistent and could not be clarified, as she was no longer employed at the facility at the time of the investigation. Interviews with facility leadership and the resident's physician confirmed that insulin should not have been administered to an unresponsive resident and that emergency services should have been contacted first. The facility did not have a specific policy regarding insulin administration during an emergency crisis, and the general medication administration policy only stated that medications are to be administered as prescribed and in accordance with good nursing practices. The physician and DON both indicated that the nurse's clinical judgment and documentation were inappropriate in this situation.