Failure to Clarify and Implement Diabetic Monitoring and Insulin Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure diabetic care and physician orders were implemented and clarified according to professional standards. For one resident with diabetes and kidney failure, the hospital after-visit summary ordered insulin aspart 6 units subcutaneously every eight hours PRN, but there was no corresponding physician order in the facility record to check the resident’s blood sugar. The resident’s care plan identified risk for abnormal blood sugars and included diabetes medication as ordered, but did not address refusals of blood sugar checks or insulin administration. Medication administration records from May 2025 through January 2026 showed no documentation that insulin aspart was administered during that period. The Medical Director stated he expected staff to check the resident’s blood sugars twice daily and administer insulin aspart for elevated blood sugars, and the ADON acknowledged staff should have clarified the hospital orders. For another resident with diabetes, morbid obesity, obstructive sleep apnea, hepatitis C, and altered mental status, the facility had physician orders for insulin lispro per sliding scale every eight hours PRN and insulin glargine 20 units subcutaneously at bedtime. A progress note documented that the resident’s blood glucose was 484, and the Medical Director ordered 24 units of Lantus, 12 units of Lispro, and a follow-up accucheck within two hours. However, the next documented blood sugar check did not occur until the following morning, with a blood glucose level of 113, and there was no documentation of any blood sugar check between the time of the elevated reading and the next morning. Interviews with facility leadership confirmed expectations that staff follow physician orders and facility policies. The Medical Director stated he was unaware whether there was an order for accuchecks for the first resident and noted that refusals made it difficult to obtain blood sugars and administer insulin, and he did not believe those refusals were care planned. The ADON stated that staff should follow policy and that CMTs could assist with accuchecks and insulin administration when nurses were behind, and the Administrator stated that the DON and ADONs should follow up on all orders written by the Medical Director. These findings show that physician orders were not clarified or fully implemented and that ordered monitoring of blood glucose was not completed as directed.
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