Failure to Administer Scheduled Medications and Blood Glucose Monitoring
Penalty
Summary
A deficiency occurred when a resident with multiple medical diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, heart failure, and atrial fibrillation, did not receive scheduled medications as ordered. The resident's care plan required regular blood glucose monitoring and administration of insulin with meals, as well as other medications for cardiac conditions. On the day in question, the resident reported not having received any medications or blood glucose checks by lunchtime, despite orders for blood glucose monitoring before meals and insulin administration. Observation and interviews confirmed that the assigned RN had not administered the resident's morning medications, nor had she performed the required blood glucose checks at the scheduled times. The RN acknowledged that the resident should have had blood sugar checks and insulin administered at specific times, but these actions were not completed. Documentation in the resident's progress notes and medication administration records further indicated that the insulin and blood glucose checks were missed until later in the afternoon, and the nurse practitioner was notified after the omission was discovered. Facility policy and the RN's job description both require medications to be administered as prescribed and within specified time frames, particularly for time-sensitive medications such as insulin and blood pressure medications. The Director of Nursing confirmed that staff are expected to follow physician orders and administer medications within the appropriate window, and that failure to do so is not acceptable. The nurse practitioner also stated that all medications are expected to be given when due and that missed doses can have adverse effects.