Failure to Administer Ordered Insulin and Delay in Emergency Transfer After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to administer insulin as ordered and to ensure timely transfer to the emergency room for a resident with multiple comorbidities, including type II diabetes, acute kidney failure, dehydration, hypervolemia, orthostatic hypotension, hypertension, anxiety, and depression. The resident had physician orders for Humulin, an intermediate-acting insulin, to be given subcutaneously at 8:00 A.M. and 4:30 P.M., with blood glucose checks before meals and at bedtime, and instructions to notify the physician for blood glucose levels over 400 or under 70. On the morning in question, the resident’s blood glucose was 240 at 7:30 A.M. and 182 at 11:30 A.M., but Humulin was not administered between 7:00 A.M. and 11:00 A.M. as ordered. There was no documentation that the physician ordered the insulin or other medications to be held, and the Medical Director later stated he was not informed that medications were held and would only hold fast-acting insulin, not long-acting insulin. Nursing documentation and interviews showed that the resident was reported as lethargic, breathing heavily, and slow to respond to voice commands beginning on the night shift, with this significant change in condition continuing into the morning. The day-shift LPN received report that the resident was not doing well and was not eating, observed the resident as lethargic and slow to respond, and wanted to send the resident to the emergency room but was told by the night nurse and the DON to continue monitoring. The LPN instructed the CMA to hold insulin if the resident did not eat breakfast, and the CMA held the morning medications, including insulin, based on this instruction and nursing judgment. The physician was called and a message sent, but there was no documented response before the resident became unresponsive late in the morning, at which time EMS was called. EMS documented the resident as unresponsive and hyperglycemic with a blood glucose too high to register on the glucometer (over 600), and hospital records later showed a glucose of 951 with diagnoses including diabetic ketoacidosis, septic shock, altered mental status, and hypotension. Facility policy required explanatory notes when scheduled medications were withheld and prescriber notification when vital medications were withheld, refused, or not available, but this was not followed for the held insulin dose.
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