Failure to Notify Responsible Party of New Insulin Medication
Penalty
Summary
The facility failed to notify the responsible party (RP) when a resident was started on a new insulin medication, Lantus, resulting in a violation of the RP’s right to be informed and involved in treatment decisions. The resident’s face sheet showed admission with diagnoses including cerebral infarction, metabolic encephalopathy, and type 2 DM. The resident’s H&P dated 8/29/2025 documented that the resident did not have the capacity to understand and make decisions, and the MDS dated 8/14/2025 indicated severe cognitive impairment with the resident rarely or never able to understand and be understood by others. A physician’s order dated 12/8/2025 directed that the resident receive Lantus 16 units subcutaneously at bedtime for type 2 DM, to be held if blood sugar was less than 150. The MAR for 12/2025 showed that Lantus was administered at 9 p.m. from 12/8/2025 through 12/31/2025. During a telephone interview, the RP stated she learned from the resident’s insurance company that Lantus had been started, and she expressed anger that the facility had not informed her of the new medication, stating that the facility undermined her authority and right to contribute to the resident’s plan of care and that she felt distrustful toward the facility. In an interview, the DON stated that review of the medical record revealed no documentation that the RP was notified when Lantus was added and confirmed there was no record of any discussion with the RP regarding Lantus prior to its initiation. The facility’s P&P titled “Change in Resident’s Condition or Status,” dated 5/2022, required prompt notification of the resident, attending physician, and representative of changes in the resident’s medical/mental condition or status and stated that a nurse or healthcare provider would inform the resident of any changes in medical care or nursing treatments, regardless of the resident’s current condition.
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