Failure to Notify Physician and Administer Ordered Insulin for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a change in condition and the holding of ordered diabetic medication for one resident. The resident was admitted with dementia and type 2 diabetes mellitus with hyperglycemia and had physician orders for Humalog insulin per sliding scale at meals and bedtime, along with care plan interventions for diabetes medication administration and blood sugar monitoring. Additional physician orders directed staff to monitor for signs and symptoms of hypoglycemia and hyperglycemia. The Medication Administration Record shows that on multiple occasions over two consecutive days, the resident’s blood sugar was not checked and Humalog insulin was not administered at scheduled times. Progress notes do not document any notification to the physician regarding the missed blood sugar checks or insulin doses. An LPN reported that on one of those days the resident was having behaviors and combativeness, later went to sleep, and remained sleeping the following day. The LPN stated she did not check the resident’s blood sugars or administer insulin because she felt sleeping was best for the resident and did not notify the physician of this. The facility’s policies on notification of changes and medication errors require prompt physician notification when there is a change requiring notification or when a medication error occurs, but there is no documentation that such notification occurred in this case.
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