Failure to Administer Insulin Due to Delayed Order Entry
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician's orders and professional standards of practice for a resident with diabetes and diabetic ulcers. Upon admission, the resident had specific physician's orders for multiple types and doses of insulin to be administered at various times throughout the day. However, due to a delay in entering these orders into the electronic health record system, the resident did not receive her prescribed insulin or other medications on the evening of admission. The orders were not entered until around midnight, causing the start date for medication administration to be set for the following day. As a result of not receiving her insulin, the resident was found the next morning with a significantly elevated blood sugar level of 503, which continued to rise despite subsequent insulin administration. The resident exhibited rapid breathing and reported feeling unwell, leading to her transfer to the hospital. She was admitted with diabetic ketoacidosis, altered mental status, acute kidney injury, encephalopathy, and dehydration. Staff interviews confirmed that the delay in order entry and medication administration directly contributed to the resident not receiving her required care.