Failure to Document Carbohydrate Counts and Insulin Doses per Sliding Order
Penalty
Summary
The facility failed to follow professional standards of practice for insulin administration and documentation for one resident with diabetes. The resident was admitted with diagnoses including breast and colon cancer, malnutrition, and diabetes, and had intact cognition and was largely independent with activities of daily living. A physician’s order dated 09/29/2025 directed that insulin be injected subcutaneously at 1 unit for every 10 grams of carbohydrates consumed after meals, with a total daily dose not to exceed 40 units. Review of the Medication Administration Records from September 2025 through 02/11/2026 showed no documentation of the amount of carbohydrates the resident consumed or the amount of insulin administered. During interviews, an LPN stated they visually assessed the resident’s meal tray to estimate carbohydrate intake and then administered 1 unit of insulin per 10 grams of carbohydrates but did not document either the carbohydrate amount or the insulin units given, and indicated there was no place on the MAR to record the units. The Nurse Manager explained that dietary staff documented the total carbohydrate count for each meal on the tray card and saved the tray for nursing to observe intake, but confirmed there was no process in place to document the carbohydrate count or corresponding insulin dose. The Medical Director stated that documentation for insulin administration should include the total carbohydrate count, the amount of insulin given each time, and the rationale for the dose. The DON similarly described a process in which dietary documented total carbohydrates and nursing calculated and administered insulin, with the expectation that nursing would document in progress notes, but acknowledged there was no process to consistently document the carbohydrate count and insulin administered. This failure was cited as not meeting professional standards of quality and placed residents at risk for unstable blood sugars, duplicate insulin administration, and adverse outcomes.
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