Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered insulin and perform ordered blood glucose monitoring for a resident with Type 2 Diabetes Mellitus and long-term insulin use. Facility policy dated 1/2015 requires medications to be administered in accordance with physician orders and documented on the Medication Administration Record. The resident was admitted with diagnoses including Type 2 Diabetes Mellitus and long-term insulin use, and the physician orders dated 12/11/25 specified Insulin Aspart 100 UNIT/ML, 30 units subcutaneously after meals for Type 2 Diabetes. The hospital discharge medication list for the same date documented that the resident was prescribed 30 units of Insulin Aspart that evening because an evening dose had not been given in the hospital. On interview, the resident reported that upon admission the facility did not have her medications or scheduled insulin and that it took two days before she received her medications. Review of the electronic Medication Administration Record (eMAR) for 12/11/25 showed no documentation that the resident received the scheduled 30 units of Insulin Aspart or that a bedtime blood sugar check was performed. The Assistant DON confirmed that if medications are not marked off on the eMAR, they were not given, and verified that the resident did not receive her evening or bedtime medications on 12/11/25, including the ordered 30 units of Insulin Aspart from the hospital discharge medication list. The resident’s admission time was confirmed as 6:49 PM on that date.
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