Failure to Follow Physician Orders and Document Medication Administration for Diabetic and Heart Failure Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure pharmaceutical services and medication administration met professional standards for two residents with significant medical conditions. One resident with type 2 diabetes mellitus was transitioned from Metformin to Glimepiride, but the MAR showed Glimepiride was not documented as administered on multiple ordered days. The same resident’s MAR also lacked documentation of ordered blood glucose checks on several specific dates, despite physician orders for monitoring. The resident’s blood sugar levels subsequently increased to over 300 starting on a noted date, leading to additional orders for Humalog Lispro insulin and an increased Glimepiride dose. After the physician ordered blood sugar monitoring three times daily with insulin administration based on results, an RN administered Humalog Lispro insulin without performing a contemporaneous blood sugar check, stating it had been checked earlier with a result of 200. Facility policy required medications to be administered in a safe and timely manner and as prescribed, and the DON stated that medications scheduled with meals must align with breakfast time, which did not occur when insulin was given around 10:05 AM instead of with breakfast. A second resident with congestive heart failure was ordered Bumetanide (Bumex) 3 mg at varying frequencies over the stay to treat edema associated with heart failure. The resident’s weight increased from 115 lbs to 127 lbs in one day and remained elevated over subsequent days. The MAR showed that Bumetanide doses were not documented as administered on several occasions, including two missed doses on one day and single missed doses on two subsequent days, despite ongoing weight gain. Nursing notes later documented that the resident was transferred to the hospital after a family member expressed concern that the resident might be experiencing fluid overload. Reference materials from the facility pharmacy and the American Heart Association described Bumetanide as a diuretic indicated for treatment of edema in heart failure and explained that edema and weight gain are common symptoms of heart failure. The DON stated that the expectation is for nurses to follow and implement physician orders, and facility policy on administering medication required that medications be given as prescribed.
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