F0760

D

Failure to Ensure Ordered Insulin Administration and Documentation

Kannapolis, North Carolina Survey Completed on 03-18-2026

Penalty

Fine: $26,685

Summary

Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from significant medication errors, specifically involving insulin administration and documentation. The resident, who was cognitively intact and had a diagnosis of type 2 diabetes, had physician orders for multiple insulin regimens, including scheduled Humalog insulin 12 units subcutaneously three times daily, Humalog Kwikpen per sliding scale before meals and at bedtime, and Lantus Solostar 38 units subcutaneously daily. The resident’s care plan directed staff to provide diabetic medications as ordered by the physician. Review of the June 2025 MAR showed numerous instances where these insulin doses were not signed as given or refused, leaving multiple blank entries across the month for all three insulin orders.

Record review revealed that for June 2025, there were missing documentation entries for scheduled Humalog doses on at least 13 days, missing entries for daily Lantus doses on several days, and missing entries for sliding-scale Humalog Kwikpen doses before meals and at bedtime on multiple occasions. The blanks on the MAR did not indicate whether the insulin had been administered or refused. A subsequent quarterly MDS again documented that the resident was cognitively intact and receiving insulin injections, and the active care plan continued to require that diabetic medications be provided as ordered, but the contemporaneous MAR for June 2025 did not reflect consistent documentation of insulin administration.

Interviews with the resident and staff further described how insulin administration was handled and contributed to the deficiency. The resident reported that during June 2025 she frequently had to ask nursing staff about receiving her insulin injections and was repeatedly told that someone would administer it, though she could not recall specific dates. Multiple medication aides stated they were not permitted to administer insulin and had to locate a nurse—such as the floor nurse, ADON, unit manager, or MDS nurse—to give insulin when due, and there was no designated nurse responsible for insulin injections on any shift. These staff, along with the ADON, MDS nurse, and a floor nurse, all reviewed the June 2025 MAR and confirmed the presence of multiple blank insulin entries, and none could recall who administered the insulin on the referenced dates. The physician stated he expected nursing staff to document when insulin was provided as ordered and, upon review of the record, noted there were no ill effects and that the resident’s accuchecks remained at baseline, but the documentation gaps remained unexplained.