Repeated Late Administration of Insulin Medications
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin medications within one hour before or after the prescribed times for three residents with diabetes. Resident E, who had intact cognition and a care plan for diabetes management, had a physician’s order for Insulin Glargine 20 units subcutaneously between 8:00 p.m. and 11:00 p.m. Review of the March 2026 MAR showed multiple instances where this insulin was given more than an hour past the ordered time window, including administrations after midnight and as late as 4:46 a.m. Resident E reported that he did not always receive his medications on time. Resident H, who also had intact cognition and diagnoses including diabetes and bilateral lower extremity amputations, had orders for Insulin Lispro 12 units subcutaneously before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m. The March 2026 MAR documented numerous occasions when these insulin doses were administered more than an hour after the scheduled times, with morning, midday, and afternoon doses all being delayed. During an interview, Resident H stated she had to wait for her medications because the nurse was busy in another Villa and had two medication passes to complete. Resident L, cognitively intact and admitted for pain and diabetes management, had orders for Lantus 10 units subcutaneously at 9:00 a.m. and Humalog per sliding scale before meals and at bedtime at 7:30 a.m., 11:30 a.m., 4:30 p.m., and 10:00 p.m. The March 2026 MAR showed repeated late administrations of both long-acting and short-acting insulin, with doses given well beyond one hour after the scheduled times, including late morning, afternoon, evening, and after-midnight administrations. Resident L reported that she could not get her pain or diabetic medications on time. During the survey, a staff member stated that medications were administered late because nurses had to stop medication passes to assist with full-body mechanical lifts, two-person transfers, or cover two separate Villas, and the facility’s Medication Administration Policy required medications to be administered as prescribed in accordance with good nursing principles and practices.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.