Failure to Document Insulin Hold and Vital Signs for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident with multiple diagnoses, including type II diabetes mellitus with hyperglycemia, cognitive communication deficit, orthostatic hypotension, dehydration, depression, generalized anxiety disorder, and acute kidney failure. The resident required assistance with bathing, personal hygiene, and mobility, and was documented as alert and oriented to person and place. Physician orders in the medical record directed that the resident receive Humulin N NPH insulin 8 units subcutaneously twice daily at 8:00 A.M. and 4:30 P.M., and insulin Aspart 5 units subcutaneously twice daily within specified morning and afternoon time windows. On the morning in question, a nurse’s progress note documented that the resident was lethargic, breathing heavily, slow to arouse, and slowly responding to stimuli, with vital signs described only as within normal limits, and that the physician and the resident’s daughter were notified. Record review showed that the resident did not receive ordered insulin that day, and there was no physician order to hold insulin in the medical record. A medication aide reported being instructed by an LPN to hold the resident’s insulin if the resident did not eat breakfast, and the aide did not administer insulin when the resident did not eat. The LPN confirmed instructing the aide to hold insulin based on nursing judgment and acknowledged that her progress note should have contained information about the decision to hold insulin, the rationale, and the actual vital sign values rather than only stating they were within normal limits. The DON verified that the medical record contained no documentation of the decision to withhold insulin, no rationale for that decision, no recorded vital sign values for that time, and no physician order to withhold insulin, despite facility policy requiring documentation of assessments, notifications, interventions, and responses when there is a change in a resident’s condition or status.
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