F0842

D

Incomplete and Inaccurate Insulin Order and MAR Documentation

Tenafly, New Jersey Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to completely and accurately document physician insulin orders and insulin administration for one resident in accordance with accepted professional standards and the facility’s own documentation policy. The resident was admitted with multiple diagnoses, including a right femur fracture, muscle weakness, type 2 DM with diabetic chronic kidney disease, heart failure, hypertension, and repeated falls, and was assessed as alert and oriented times three. The Order Summary Report (OSR) as of 07/23/2025 showed multiple insulin orders: Admelog sliding scale before meals, Humalog sliding scale before meals and at bedtime, and three separate Lantus bedtime dose orders (16 units, then 22 units, then 10 units), but no further insulin orders beyond these. The facility’s policy required that all medications administered and services performed be documented in the clinical record.

Review of the Medication Administration Record (MAR) for July 2025 revealed inconsistencies and missing documentation relative to the OSR and progress notes (PN). For Lantus 16 units at bedtime, the MAR showed a code 9 entry on 07/22/2025, with the chart code indicating “Other/See Progress Notes,” and the PN documented that the nurse was awaiting pharmacy delivery; however, there was no PN entry indicating that the medication was not received or that the MD was notified, despite LPN #1 later stating that the RN supervisor called the MD and obtained a one-time short-acting insulin order. The MAR also showed a one-time Admelog 4-unit dose on 07/22/2025 at 10:03 PM and a one-time Admelog 7-unit dose on 07/23/2025 at 2:47 AM, but these one-time orders were not reflected on the OSR. A PN at 2:10 AM on 07/23/2025 documented a phone order for 7 units x1 dose but did not specify the insulin type.

Further discrepancies occurred with sliding scale insulin and Lantus dose changes on 07/23/2025. The MAR documented administration of Admelog per sliding scale for a blood sugar of 341 at 11:30 AM and a code 9 entry for a blood sugar of 400 at 4:30 PM, while PNs by an LPN described blood sugars “over 400 mg/dl since last night and during lunch,” extra 2-unit Admelog doses, and communication attempts with the MD and endocrinologist. Another PN documented obtaining a new order to increase Lantus to 22 units nightly and giving another 2 units for blood sugar coverage, but the OSR and MAR did not consistently reflect all of these specific coverage doses. Later PNs documented new orders to change the lispro sliding scale and to discontinue the current Lantus and decrease it to 10 units, and a 10:20 PM PN described an MD order for 8 units of insulin prior to dinner, with Lantus and 8 units of coverage given for a blood sugar of 402 at 9:02 PM; however, there was no corresponding physician order on the OSR or order entry on the MAR for this medication. Interviews with nursing staff and the DON confirmed that some insulin doses were documented only in PNs as late entries, that the RN supervisor did not document MD communication, and that documentation on the MAR did not coincide with or timely reflect the insulin orders and administrations, contrary to the facility’s charting and documentation policy.

Interviews with staff and the resident’s MD further highlighted the documentation failures. LPN #1 confirmed using code 9 on the MAR and documenting “awaiting RX delivery” in the PN for the 16-unit Lantus order and stated she did not administer the Lantus because the facility was waiting for pharmacy delivery, and that the RN supervisor notified the MD and obtained a one-time short-acting insulin order, which was not fully documented in the PNs. The RN supervisor stated she could not recall the exact blood sugar or details of the MD call and acknowledged she did not document at the time, assuming the nurse would document in the PNs. The DON acknowledged that an LPN’s late-entry documentation of insulin given did not coincide with or timely appear on the MAR. The resident’s MD stated that nurses called when the patient was admitted, that the blood sugar was over 400, and that the insulin order given was based on the hospital sliding scale, but the facility’s records did not fully or accurately capture these orders and administrations. Collectively, these findings show that the facility failed to maintain complete and accurate physician orders and medication administration records for insulin for this resident, in violation of professional standards and the facility’s own documentation policy.