Failure to Transcribe and Administer Insulin Orders on Admission
Penalty
Summary
Staff failed to ensure that a resident with type 2 diabetes mellitus received prescribed insulin upon admission. The resident was admitted with hospital discharge orders for both Humalog (fast-acting insulin) and insulin glargine (long-acting insulin), including specific sliding scale instructions for administration. However, these orders were not transcribed onto the facility's physician order sheet or medication administration record (MAR) at the time of admission. For six days following admission, the resident did not receive the prescribed insulin. Documentation shows that blood glucose checks were performed, but insulin was not administered as ordered until the issue was identified and new orders were obtained from the physician. Interviews with staff revealed that the admitting nurse was responsible for transcribing discharge medications, and the DON and ADON were expected to review these orders the day after admission. This review did not occur, and the omission was only discovered after the resident and staff raised concerns about missing insulin orders. The resident reported not receiving insulin since admission and expressed concern to staff. Multiple staff interviews confirmed that the process for transcribing and double-checking new admission medication orders was not followed, resulting in the resident missing critical diabetes medication for several days. The facility's policies required medications to be administered as prescribed and for errors to be analyzed and corrected, but these procedures were not adhered to in this instance.