A Buffalo, NY, nursing home has been hit with a $47,827 fine after its medical director ordered insulin for a patient whose recent hospital discharge papers said she should no longer have it.
The actual harm fine, stemming from a 2018 incident, was the sixth-largest in New York last year, The Buffalo News reported.
The case involved a diabetic resident who had been found unresponsive twice in her bed at Humboldt House Rehabilitation and Nursing Center. She was revived using medication and fruit juice, and then sent to the hospital by early the next morning, according to a state health department report.
When she returned from the hospital about a week later, her discharge notes clearly stated that she should no longer receive either long- or short-acting insulin.
Despite the notes’ bold letters and repeated phrasing, the nursing home’s medical director approved a new order for insulin by phone and signed off on it. In the inspection report, the director blamed the mix-up on a nurse who misread the directive to him. The physician also guessed that the resident’s initial hospitalization might have been caused by accidentally discontinued glucose readings — possibly due to a change to the woman’s electronic medical record.
“I would have to think someone mistakenly clicked on something and caused it to be deleted,” he told inspectors.
The director also acknowledged that he did not follow his typical practice of reading the discharge summary when he examined the woman.
Humboldt House Administrator Isaac Williams did not return a call from McKnight’s seeking comment.
But officials at the facility told the Buffalo News that they have provided additional nurse training about blood glucose testing of diabetic residents. Williams also noted that the fine reflected care of only one resident, who was later discharged in good health.