Failure to Monitor Blood Glucose After Initiation of Long-Acting Insulin
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice after initiation of a new long-acting insulin order. The resident, who had type 2 diabetes mellitus with diabetic chronic kidney disease and unspecified dementia with severe cognitive impairment (BIMS score of 6/15), had a documented blood sugar of 439 mg/dL on 1/8/26. Following this elevated blood sugar result, the physician ordered Lantus insulin glargine 5 units subcutaneously once daily for type 2 diabetes. Lantus is a long-acting insulin whose most common side effect, as noted in the manufacturer’s information, is hypoglycemia, which may be serious and life threatening. Record review of the resident’s EMR showed no documentation that the resident’s blood sugar was monitored after administration of the newly prescribed Lantus to evaluate the effectiveness of the treatment or to monitor for possible side effects. The DON confirmed that there was no follow-up re-evaluation of the elevated blood sugar after the 5 units of Lantus were given by the LPN, and also confirmed there was no documentation of the incident or receipt of the order in the resident’s electronic health record. The physician stated that the nurse had called to report the high blood sugar and that she ordered the 5 units of Lantus, but there was no subsequent documented monitoring of the resident’s blood sugar following administration.
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