Insulin Administered Outside Ordered Blood Glucose Parameters
Penalty
Summary
The deficiency involves the administration of insulin outside of ordered parameters, resulting in unnecessary medication for a resident. The resident was admitted with diagnoses including nontraumatic intracerebral hemorrhage, type 2 diabetes mellitus with hyperglycemia, and metabolic encephalopathy. A physician’s order dated July 22, 2025, directed that Lantus (insulin glargine) 20 units be given subcutaneously at bedtime for diabetes mellitus and held if blood glucose was under 120. This order was later discontinued on November 9, 2025, and replaced with a new order for Lantus 15 units at bedtime with the same instruction to hold if blood glucose was under 120. A quarterly MDS assessment documented that the resident had memory problems, severely impaired cognitive skills, and had received a daily injection for seven days prior to the assessment. Review of the November 2025 MAR showed that Lantus 20 units was administered on November 4 and 5 when the resident’s blood glucose readings were 117 and 118, respectively, which were below the ordered hold parameter of 120. After the dose was changed to 15 units on November 9, the MAR showed that Lantus continued to be administered outside the ordered parameters on multiple dates: November 16 with a blood glucose of 113, November 19 with 90, November 20 with 98, November 22 with 88, and November 23 with 86. These administrations occurred despite the standing order to hold the insulin if blood glucose was under 120. Further review of the clinical record revealed no evidence that the provider was notified about the resident’s blood sugar status or that Lantus had been administered outside the ordered parameters on any of those dates, and there were no updated orders or documented rationale for giving the medication outside parameters. In interviews, an RN stated that insulin must be administered within provider-ordered parameters and that administering insulin outside of orders could cause hypoglycemia, and also stated that the only exception would be if the provider had ordered it. The DON confirmed that the Lantus doses had been given outside the ordered blood glucose parameters and that there was no documentation of provider notification or updated orders, and stated that staff are expected to hold medications when results fall outside ordered parameters and to document the occurrence in progress notes. Facility policies on physician orders and medication administration required that medications be administered only in accordance with written physician orders and that any irregularity or question regarding dosage be clarified with the physician before administration.
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