Failure to Administer Insulin per Physician Orders During Resident Absence
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes and diabetic kidney complications who was admitted in July 2025. Physician orders dated September 2025 directed staff to administer insulin glargine twice daily for diabetes management. Documentation showed that during five morning medication administrations, the resident was absent from the facility without her/his medications. Staff interviews revealed that the resident left the facility before the morning shift began to attend dialysis and returned in the afternoon. The LPN responsible for the morning shift was unaware of whether the night nurse had administered the insulin or if it was sent with the resident to dialysis. The regional nurse confirmed that physician involvement would be expected in developing a clinical plan for insulin administration while the resident was out of the facility.