§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on clinical records review and staff interview, it was determined the facility failed to follow the physician's order regarding medication for one of the 12 residents reviewed (Resident 44)
Findings include:
Review of Resident 44's clinical record including diagnosis list includes Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period).
Review of Resident 44's clinical record including physician order dated June 20, 2023, revealed an order of Novolog (fast-acting insulin) Flex Pen U-100 Inulin administered seven units subcutaneously (Insertion of medication beneath the skin by injection) with meals. Hold if blood sugar is below 180 mg/dl.
Review of Resident 44's clinical record including January 2024, Medication Administration Record (MAR) revealed from January 1, 2024, until January 31, 2024, Novolog insulin was administered to the resident on the following days out of parameter: January 9, 2024, at 8:00 a.m., (BS-134 mg/dl); January 13, 2024, at 8:00 a.m., (BS-140 mg/dl); January 15, 2024, at 8:00 a.m., (BS-97 mg/dl); January 16, 2024, at 8:00 a.m., (BS- 124 mg/dl); January 18, 2024, at 8:00 a.m., (BS- 143 mg/dl); January 22, 2024, at 8:00 a.m., (BS- 108 mg/dl); January 22, 2024, at 12 noon, (BS- 165 mg/dl); January 23, 2024, at 8:00 a.m., (BS- 90 mg/dl); January 23, 2024, at 12 noon, (BS- 90 mg/dl); January 24, 2024, at 8:00 a.m., (108 mg/dl); January 25, 2024, at 8:00 a.m., (BS- 153 mg/dl); January 27, 2024, at 8:00 a.m., (BS- 102 mg/dl); January 28, 2024, at 8:00 a.m., (BS- 129 mg/dl); January 29, 2024, at 4:00 p.m., (BS- 125 mg/dl).
Review of February 2024 MAR revealed that from February 1, 2024, until February 22, 2024, Novolog insulin was administered to the resident on the following days out of parameter: February 1, 2024, at 8:00 a.m., (BS- 143 mg/dl); February 2, 2024, at 8:00 a.m., (BS- 171 mg/dl); February 3, 2024, at 8:00 a.m., (BS- 172 mg/dl); February 7, 2024, at 8:00 a.m., (BS- 124 mg/dl); February 7, 2024, at noon, (BS- 156 mg/dl); and February 19, 2024, at 4:00 p.m., (BS-139 mg/dl).
Review of Resident 44's clinical record revealed Resident 44 was administered Novolog Insulin outside of parameter 14 times in January 2024, and six times in February 2024.
The above information was conveyed to the Director of Nursing on February 23, 2024, at 11:00 a.m.
The facility failed to ensure Resident 44's insulin parameters order was followed.
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
| | Plan of Correction - To be completed: 04/23/2024
On 02/23/2024 physician order for resident 44 Novolog insulin was reviewed by physician, and order was discontinued. A new order was given by physician to check blood sugar twice a day and follow sliding scale with insulin coverage. House audit: All residents receiving insulin with parameters will be audited to ensure order was followed correctly.
Nurses will be educated on following insulin orders and utilizing sliding scale coverage.
Audit of insulin orders will be completed for accuracy weekly x 4 then monthly x 2.
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