Failure to Administer Insulin and Monitor Blood Sugar as Ordered
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the administration of insulin and monitoring of blood sugar levels for two residents with diabetes mellitus. For one resident, multiple instances were identified where blood sugar checks were not performed and prescribed insulin doses, including Lispro, Lantus, and Glargine, were not administered as ordered by the physician. Documentation showed missed insulin doses at various scheduled times, and in some cases, insulin was administered even when blood sugar levels were below the threshold specified in the physician's order. The Executive Director acknowledged the missed doses during an interview but provided no further information. For another resident, similar deficiencies were observed, including failure to administer sliding scale Lispro insulin when blood sugar readings indicated it was required, and missed doses of Glargine insulin at bedtime. The resident's care plan and physician's orders clearly outlined the need for insulin administration based on blood sugar results, but the Medication Administration Records revealed several occasions where insulin was not given as ordered. The Administrator confirmed the missed dosages and had no additional information regarding these omissions. The facility's medication administration policy required medications to be given as ordered by the physician.