Insulin Administered Contrary to Ordered Blood Glucose Parameters
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure residents were free from significant medication errors, specifically involving the administration of insulin contrary to physician orders. One male resident with multiple diagnoses, including dementia, mild cognitive impairment, morbid obesity, schizophrenia, essential hypertension, type 2 diabetes, and acute kidney failure, had a physician order for Lantus SoloStar (insulin glargine) 10 units subcutaneously once daily with a clear parameter to hold the dose if blood glucose was less than 120. His comprehensive care plan for diabetes included goals to prevent signs and symptoms of hyperglycemia and hypoglycemia and to avoid complications related to diabetes, with an intervention to administer diabetes medication as ordered by the physician and monitor for side effects and effectiveness. Review of the resident’s electronic MAR for a two‑month period showed that multiple nurses, including LVNs and the ADON, documented administering Lantus even when the resident’s blood glucose readings were below the ordered hold parameter of 120. Specific documented administrations included doses given when blood glucose values ranged from 84 to 118, on numerous dates across January and February, by several different licensed nurses. Each of these administrations was recorded with a check mark on the MAR, which staff confirmed indicated that the medication had been given. In interviews, one LVN stated that if a blood sugar was below the parameter, she would be expected to hold the insulin and that there would be no reason to give insulin outside the ordered parameters, acknowledging that doing so could cause the resident’s blood sugar to “bottom out.” She also stated she believed the order previously did not have parameters and was unsure when it changed. The DON confirmed that the Lantus order included a parameter to hold if blood glucose was less than 120 and that a check mark on the MAR meant the medication was administered. The DON stated that if blood sugar was below the parameter, the insulin should be held and that nurses should be aware of order changes discussed in the 24‑hour report and IDT meetings. The attending physician stated that if the resident’s blood sugar was under the parameter, nurses should not administer the Lantus and that all nurses were expected to follow his orders. The facility’s policy on physician orders required nurses to review orders, clarify them as needed, and ensure they were accurately entered and directed to the appropriate electronic administration record.
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