Failure to Administer Prescribed Insulin Resulting in Hospital Transfer
Penalty
Summary
A resident with diagnoses including end stage renal disease and dysphagia was admitted to the facility with a physician's order for Insulin Lispro to be administered subcutaneously three times daily. Review of the Medication Administration Record revealed that the resident did not receive any of the 17 prescribed doses of Insulin Lispro over a six-day period. Staff interviews confirmed that the assigned nurse did not recall administering the medication, and the Director of Nursing Services was unable to provide evidence that the insulin was given as ordered. Facility policy required subcutaneous insulin to be administered safely and accurately according to provider orders. During this period, the resident experienced persistently elevated blood glucose levels, with documented readings significantly above the normal range for diabetics. The resident's condition deteriorated, as evidenced by lethargy, low blood pressure, elevated heart rate, and critically high blood glucose levels, ultimately resulting in transfer to an acute care hospital. The Nurse Practitioner confirmed that staff were expected to follow provider orders for medication administration.