Failure to Notify Resident Representative of Repeated Insulin Refusals and Missed Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative when the resident repeatedly refused ordered insulin and when staff did not monitor blood sugar values as ordered. The resident was admitted with type 2 diabetes mellitus with a foot ulcer, difficulty in walking, and a non‑pressure chronic ulcer of the right foot with necrosis of muscle. A quarterly MDS documented a BIMS score of 9/15, indicating some cognitive impairment. The resident had orders for HumaLOG insulin per sliding scale before meals and at bedtime, and Lantus insulin at bedtime for diabetes management. Review of the MAR for November showed multiple instances where blood sugar monitoring was not completed as ordered and/or insulin was not administered. For HumaLOG, there were 16 occurrences in November where blood sugar values were either marked as not applicable or left blank at various times (0630, 1130, 1630, and 2100), indicating that blood sugar was not checked to determine if insulin was required. For Lantus, four doses in November were documented with the code "2" for drug refused. The medical record for this period did not contain documentation that the resident’s representative was notified of either the refusals or the missed blood sugar monitoring. In December, the pattern continued. The Lantus dose was increased to 25 units at bedtime, and the MAR documented five additional refusals of Lantus using the code "2". For HumaLOG, there were 15 occurrences in December where blood sugar values were not monitored, documented as not applicable or with an "X" at various scheduled times. Again, the medical record did not show that the resident’s representative was notified of the resident’s refusals of insulin or of staff not monitoring blood sugar values. The resident’s representative later stated they were not aware of the refusals and had not been told the resident was non‑compliant. An LPN reported that while they call the physician and sometimes family when refusals are frequent, they did not notify this resident’s family. The DON stated the expectation was that nurses notify family and the provider and document when a resident refuses medications or treatments, and that the resident’s refusals had been discussed in morning meetings. The facility’s Notification of Changes policy required notifying the resident’s representative of clinical complications and significant changes in health status.
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