Inaccurate Documentation of Insulin Administration by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) documented in the medical record that she administered Lantus (insulin glargine) to a newly admitted resident with type 2 diabetes, when in fact the medication was not given. The resident's medical record, including the Medication Administration Record (MAR), indicated that the insulin was administered as ordered by the physician. However, during interviews, the LVN admitted she did not administer the insulin because she assumed it had not yet arrived from the pharmacy, and she inadvertently documented its administration while intending only to record the completion of blood glucose monitoring (accuchecks). The LVN also acknowledged that the insulin was available in the facility's emergency medication kit but did not access it or administer the medication. The resident, who had recently been admitted with diagnoses including acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, and primary open-angle glaucoma, reported not receiving her insulin on her first night in the facility but had no adverse effects and had informed staff. The facility lacked a specific policy addressing documentation accuracy, and the existing medication administration policy did not cover documentation procedures. The interim Director of Nursing Services (DNS) confirmed the documentation error and emphasized the importance of accurate record-keeping and following physician orders.