Failure to Follow Physician Orders for Insulin Administration and Blood Glucose Notification
Penalty
Summary
The facility failed to implement physician orders for three residents with diabetes and related conditions. For one resident with diabetes, chronic kidney disease, and heart failure, staff administered a short-acting insulin injection (Admelog) at 12:15 p.m., but the resident did not receive her meal until 1:15 p.m., an hour after the insulin was given, contrary to manufacturer instructions and physician orders that specified insulin should be administered 15 minutes before or immediately after a meal. Another resident with diabetes, diabetic retinopathy, chronic kidney disease, and dementia was administered Humalog insulin at 11:15 a.m., but did not receive her meal until 1:24 p.m., over two hours later, also in violation of the prescribed timing for insulin administration. Staff interviews confirmed that insulin was not administered in accordance with physician orders and manufacturer guidelines. Additionally, for a third resident with hyperglycemia, dementia, diabetes, and chronic kidney disease, staff failed to notify the physician when blood glucose readings exceeded 400 mg/dL, as required by a physician's order. Blood sugar logs showed readings of 424 mg/dL and 416 mg/dL on two separate occasions, with no evidence of physician notification. The Director of Nursing confirmed that there was no documentation of physician notification for these elevated blood glucose levels.