Failure to Administer Ordered Insulin and Perform Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a resident with Type 2 Diabetes Mellitus and a G-tube did not have blood glucose monitoring and insulin administration performed as ordered. The resident’s admission record showed diagnoses including Type 2 Diabetes Mellitus with hyperglycemia and gastrostomy status, and the MDS assessment documented intact cognition with a BIMS score of 15 and a diagnosis of Diabetes Mellitus. The resident’s care plan, initiated in April 2023, identified imbalanced nutrition related to insulin resistance and risk for complications such as unstable blood glucose and cardiovascular disease, with an intervention specifying diabetes medication as ordered by the physician. During an interview with the resident and the resident’s responsible party, both reported that the resident’s blood sugar was not checked and insulin was not administered on multiple occasions, including a specific evening. Review of the MAR for that date and time confirmed that the resident’s blood sugar was not checked and Humalog insulin, ordered every six hours per sliding scale, was not given at the scheduled 6:00 p.m. dose, and the licensed nurse did not document any justification for the missed insulin administration. The facility’s policies on diabetes care and medication administration required following provider orders for blood glucose monitoring, assisting with the prescribed medication regimen, and administering medications safely, timely, and in accordance with prescriber orders within one hour of the prescribed time, which was not followed in this instance.
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