Failure to Timely Enter Physician Orders Results in Missed Insulin and Hospitalization
Penalty
Summary
A deficiency occurred when a new resident with a history of diabetes and diabetic ulcers was admitted to the facility. Although the resident's physician's orders for multiple insulin regimens were reviewed with the provider on the evening of admission, these orders were not entered into the electronic health record in a timely manner. As a result, the resident did not have any medication orders available in the system for the day of admission, and missed both supper and bedtime insulin doses. The delay in entering the orders was confirmed by the Director of Nursing, who stated that the responsible RN did not input the orders until around midnight, causing the orders to be set to start the following day. The resident was found the next morning still on hospital linens, with a soiled brief and an elevated respiratory rate. Blood glucose readings were critically high, with initial values of 503 and subsequent readings remaining above 480 despite insulin administration. The resident reported feeling unwell and was subsequently sent to the hospital, where she was admitted to the ICU with diabetic ketoacidosis, altered mental status, acute kidney injury, encephalopathy, and dehydration. Review of clinical records and staff interviews confirmed that the failure to timely enter and implement physician's orders directly resulted in the resident missing essential insulin doses and requiring hospitalization.