F0580

D

Failure to Notify Physician of Repeated Insulin Refusals

Reseda, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the physician when a resident repeatedly refused ordered insulin injections, contrary to federal requirements for notification of significant changes and the facility’s own policy. The resident, who had diabetes mellitus with diabetic polyneuropathy and peripheral vascular disease, was originally admitted in 2023 and re-admitted in 2025. A History and Physical dated 2/27/2026 documented that the resident had decision-making capacity and an HbA1c of 8.9%, above the stated goal of less than 8%. The resident’s MDS indicated intact cognition for daily decision-making.

The physician’s order, effective since 3/21/2025, directed administration of Novolog 8 units subcutaneously once daily at 7:30 a.m. for diabetes management, with instructions to hold the dose if blood sugar was less than 100 mg/dL. Review of the MAR for 3/1/2026 to 3/10/2026 showed that the resident refused the scheduled Novolog injections on multiple mornings: 3/1, 3/4, 3/5, 3/6, 3/7, and 3/9. The DON confirmed that the order required daily administration and acknowledged that the resident had a tendency to refuse insulin injections.

Review of progress notes for the same period, conducted with the DON and later with an LVN, revealed no documented evidence that the physician was informed of the repeated insulin refusals. Both the DON and LVN stated that licensed nurses should have notified the physician of these refusals, particularly when they occurred on consecutive days. The facility’s “Medication Administration” policy, revised 4/16/2025, specified that the DON and attending physician must be notified when two consecutive doses of medication are refused or withheld. The DON confirmed that this policy was not followed in the resident’s case, resulting in the cited deficiency for failure to notify the physician of repeated insulin refusals.

Plan Of Correction

Corrective Action for Affected Residents: On 3/12/2026, the RN Unit Manager notified Resident 94's physician of the multiple insulin refusals that occurred on 3/1/2026, 3/4/2026, 3/5/2026, 3/6/2026, 3/7/2026, and 3/9/2026. On 3/12/2026, the RN Unit Manager obtained physician orders for Resident 94 regarding the management of insulin refusals and alternative diabetes management strategies.

Identifying other Residents having the Potential to be Affected: On 3/25/26, the Medical Records Manager conducted an audit of the Medication Administration Records (MARs) for residents receiving insulin for the period of 3/1/2026 through 3/25/2026 to identify instances where residents refused two or more consecutive doses. No other residents in the facility were identified as refusing insulin.

Measures put into place or Systemic Changes: The DON and/or Director of Education in-serviced licensed nurses on the "Medication Administration" policy, with emphasis on the requirement to notify physicians of two consecutive medication refusals, particularly insulin and other critical medications, and the importance of timely documentation of physician notification in the resident's progress notes.

Plan to Monitor Performance: Beginning 4/6/2028, the contracted Medical Records Consultant will conduct random audits during scheduled monthly visits of the MARs and corresponding progress notes for residents receiving insulin or other critical medications to verify that licensed nurses are notifying physicians when residents refuse two consecutive doses and documenting such notifications appropriately. The audits will include a sample size of at least ten percent of residents receiving insulin or other critical medications. The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.