Failure to Follow and Document Insulin and Blood Glucose Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders for blood glucose monitoring and insulin administration were accurately carried out and documented for a resident with multiple complex diagnoses. The resident was admitted with schizophreniform disorder, bipolar disorder, generalized idiopathic epilepsy, type 2 DM with foot ulcer, and unspecified intellectual disabilities, and had an MDS BIMS score of 5 indicating severely impaired cognition. The physician’s order required subcutaneous Insulin Aspart before meals with a fingerstick blood sugar (BS) obtained prior to meals. Review of the MAR showed multiple instances over several months where BS values were documented as “NA” with chart codes indicating drug refusal or “other/see nurses note,” as well as one entry marked “X” with a code for “no insulin required,” without supporting documentation. There were also entries where BS and insulin administration boxes were left completely blank, with no BS, no insulin, and no explanatory documentation. During interviews, the DON stated that for residents with intellectual disabilities who refuse medications, staff are expected to encourage the resident, notify the physician and responsible party, and document these contacts as a change in condition or progress note, and that it would not be acceptable to simply mark a resident as sleeping and not administer medication. The DON further explained that “NA” had been used when BS was not obtained, and confirmed that BS should have been obtained for each shift where “NA” was documented and that sleeping was not an acceptable reason to omit BS checks. The DON acknowledged there was no documentation that the provider was notified when the resident refused, and confirmed that blank MAR boxes indicated no documentation was completed. She affirmed that the expectation was for nurses to carry out physician orders and document BS results, insulin administration, and insulin amounts, which did not occur as required for this resident.
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