Failure to Administer Insulin as Ordered Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not administering insulin as ordered to four of eight residents with diabetes. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. Clinical record reviews showed that residents with diagnoses including hypertension, cerebrovascular disease, and Type 2 diabetes had physician orders for scheduled insulin administration. On the specified date, a registered nurse obtained blood sugar readings for several residents but did not administer the required insulin coverage before meals as ordered. In one case, a blood sugar reading was not obtained, resulting in no insulin being given. Documentation and staff interviews confirmed that the missed insulin doses were identified by the RN Supervisor, and the responsible RN acknowledged not covering the residents' blood sugars after obtaining accuchecks, stating that priorities were not in line and residents were put at risk. The Director of Nursing and Assistant Director of Nursing confirmed the failure to administer insulin as ordered, which constituted neglect under facility policy and state regulations.