Failure to Administer and Document Insulin and Antipsychotic Medications as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with dementia and diabetes mellitus when ordered blood glucose testing and insulin administration were not consistently completed or documented. The resident had a care plan for diabetes indicating medications would be administered as ordered and an MDS showing she received insulin and an antipsychotic. A physician’s order required Humalog insulin to be given twice daily at specific times based on sliding-scale dosing after blood glucose testing. The MAR for one month showed that blood glucose testing was not completed at several ordered times, and there was no documentation of blood sugar results or whether insulin was or was not administered. No corresponding glucose results were found in progress notes or blood glucose listings. The facility also failed to follow physician orders and care plan interventions related to an antipsychotic medication, olanzapine, ordered three times daily for psychosis. The MAR documented repeated refusals of the 6:00 a.m. dose on numerous days over two consecutive months. There was no documentation that the physician had been notified of these missed doses, no evidence that the care plan intervention to crush medications as needed had been implemented, and no documentation of the reasons for the refusals. During interview, the DON reported that the nurse assigned on the refusal days stated the resident was agitated in the morning, and no other interventions had been attempted, despite a facility policy stating medications were to be administered in a safe, accurate, and effective manner.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.