Failure to Administer Insulin per Physician Orders and Manufacturer Instructions
Penalty
Summary
Surveyors identified that the facility failed to ensure insulin was administered in accordance with physician's orders and manufacturer instructions for three residents observed for insulin administration. For one resident with type 2 diabetes and a history of hyperglycemia and ketoacidosis, insulin was routinely administered after meals instead of before meals as ordered. The resident repeatedly complained to staff about high blood sugar readings, delayed insulin administration, and lack of timely physician notification for additional insulin coverage. Documentation showed that blood sugar readings were frequently elevated, with only sporadic documentation of physician notification for extremely high readings. The resident's care plan was not updated after admission, and there were lapses in providing a replacement for his continuous glucose monitoring device. Another resident with type 2 diabetes and diabetic neuropathy was observed receiving Lantus insulin after finishing breakfast, rather than at the prescribed time. The resident's orders required blood glucose testing before meals and timely administration of insulin, but observations and record reviews indicated that insulin was not consistently administered as ordered. Similarly, a third resident with type 2 diabetes was observed receiving Lantus insulin after her blood sugar was checked, with staff indicating that insulin was given according to resident preference or when breakfast trays were served, rather than strictly following the prescribed timing. Interviews with nursing staff revealed inconsistent practices regarding the timing of insulin administration, with some staff prioritizing convenience or resident requests over adherence to physician orders and manufacturer guidelines. Staff also reported challenges in locating residents at medication times and managing multiple diabetic residents, which contributed to delays and deviations from prescribed protocols. Facility policies required medications to be administered as prescribed and at the right time, but these were not consistently followed, resulting in significant medication errors for the residents involved.