Insulin Administered Outside Ordered Blood Sugar Parameters
Penalty
Summary
The facility failed to ensure insulin was administered according to physician-ordered blood sugar (BS) parameters for a resident with diabetes mellitus type 2. The resident had an active order for Novolog insulin 10 units subcutaneously with meals, with instructions to hold the dose if BS was less than 150. Review of the December 2025 MAR showed that on four separate mornings, the nurse documented BS readings below 150 (122 on three dates and 106 on one date) and still administered 10 units of Novolog insulin at approximately 6:30 AM each time. Subsequent BS readings later those days were also documented, including elevated values and one instance where the resident refused a later BS check. During a telephone interview, the nurse stated she did not recall any parameters for the resident’s Novolog insulin and believed that if parameters existed, they would appear on the electronic MAR. She confirmed that her documentation indicated she administered 10 units of Novolog on the identified dates and times. The resident’s MDS showed he was cognitively intact, had no behaviors or rejection of care, and received insulin injections on most days in the look-back period. The NP reported familiarity with the resident, noting he frequently refused BS checks and insulin and that his BS tended to run high, but acknowledged that insulin should be given according to ordered parameters. The DON stated that administering insulin outside the physician’s parameters was considered a serious medication error, and the Administrator stated nurses should adhere to physician parameters when administering insulin.
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