Need help regarding insulin policy in LTC

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i am a new grad and was working at a snf for 3 weeks when i had an incident where the day shift nurse went home with the only backup keys to the treatment cart so i did not have access to the resident's insulin before their meals. notified the rcm and charge of the event and did what i could at the time which was to check the resident's cbg. none of the # were critically high/low that would required me to proceed with the hyper/hypoglycemic protocol. i was told by the rcm to recheck the residents cbg after their meal and administer the ordered dose of insulin. i did what was told and rechecked their cbg after meal and administer insulin according to this second value. a week later was let go due to "inadequate quality of work, insubordination, and poor use of judgement regarding insulin." the dns said i made a med error because i was supposed to administer the insulin according to the first cbg not the second. in addition, i was not supposed to the implement sliding scale for a resident after his meal (even though it was dr. order to give a scheduled dose and an additional sliding scale if it's over xyz before meals). i explained to the dns what i was told to do by the rcm but was told that that was not what the rcm was trying to convey. looking back i understand why it makes more sense to give insulin using the first cbg but i guess i got a little frantic and went with what the rcm said. *sigh, what bothered me the most was that i was given 3 days to follow 3 different nurses and was tossed out there to fend for myself. they claimed that they had extensively educated me on diabetic management which consisted of what to do if a resident was hypo/hyperglycemic and how to take t.o. orders regarding insulin! funny thing is they offered me a position as a cna, which i worked for them as before i got my license. of course i declined and thank them for the short opportunity.

so my question is: is there a general policy regarding insulin administration that pertain to my situation or did i just fell asleep during the diabetic management lecture??

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Specializes in geriatrics.

I can't say for sure, because every facility has different policies. There may have been other reasons why you were dismissed. As far as the insulin, I would have called the nurse and asked her to bring the keys back, and/or asked the charge where the spare set of keys were. Phone them at home if you have to. Then, I would have notified the Dr and asked for his advice. You need orders in cases such as this and proper documentation to cover yourself.

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Specializes in Cardiac, PCU, Surg/Onc, LTC, Peds.

Yes you definitely need to call the MD to cover yourself and get appropriate orders if there is not the correct medication to administer as ordered. The RCM was wrong in what she instructed you to do. But sadly it sounds like she/he is singing a different tune now when called to the carpet and has thrown YOU under the bus. I can guarantee this would have happened to you again at that facility, count your blessings you were dismissed, it's saved you a lot of headache.

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Specializes in Hospital Education Coordinator.

I am a diabetic educator and a diabetic and can tell you it is very difficult to keep up with all the meds, protocols, etc. That is why you need MD order. You learned from this and no one was hurt. If you had stayed longer in a facility where so little support is given the next mistake might have turned out so much differently. Wish you luck in your new position and yes, I would not try to hide that employment on my record. Better to fess up because SOMEBODY knows you worked there and gossip travels fast

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I did call the day shift nurse and she came back with the keys a little over an hour later, and that's when I rechecked the CBG and administer the insulin.

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I'm sorry you were put in this situation. From your post I understand that you checked the patients insulin at the proper time, were required to give insulin but didn't have any, and then rechecked when you had insulin on hand and that is when you gave it?

So the blood sugar you were covering would have been higher due to the patient eating, which meant you gave higher coverage.

And what the supervisor had told you was to give the insulin dose according to the first value. Which makes sense.

You were still new to nursing and to the facility and I can understand being confused about what to do.

Diabetic protocols can be extremely confusing, and they differ from one patient to the next, and if you have a lot coming at you I can see getting flustered and making a mistake.

Standard procedure is to dose the insulin according to before meal values.

I would understand them writing you up for this and maybe re-educating, but I think it was kind of extreme to fire you.

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Good riddance to this place. Be thankful you are out of there with your license intact. Does not seem like a very safe or stellar work environment having given you only 3 days orientation.

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Thank you everyone for the feedback! I accept responsibility for what happened and know this experience will make me become a better nurse! I just hope my future employer will be sympathetic!

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That place sounds like a hot mess. I have never even heard of keeping insulin in a "treatment" cart. I can't believe the supervisor didn't bring a spare set of keys (if they don't have one...that's really dumb) and barring a second set of keys that she couldn't find you a freaking vial of humalog and regular or whatever you needed to give for coverage for you to use until you got the keys back. Additionally, yes, if you ever have ANY questions when it comes to insulin administration always call the doctor and get an order. Call the doctor and get an order if you are doing anything at all that deviates from the order you have for the insulin and accuchecks for any reason.

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Specializes in Rehab, LTC, Peds, Hospice.

I'm surprised there wasn't an emergency supply of insulin. Insulin is normally given on a sliding scale based on a fasting blood sugar. Results obtained after a patient has eaten 'post prandial' are always higher - which is why the amount of insulin you probably gave was more than what you would've given at the proper time before the meal and incorrect as the patient was not fasting at that time. Insulin can be very dangerous when given improperly or even as ordered. When in doubt, definitely call the doctor.

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For as long as you live and you are a nurse please, please ALWAYS GET AN MD ORDER for anything that is not on the MAR. The DON and charge nurse know they screwed up because their system is flawed. They probably decided to say that the RCM was telling you something different in order to put the blame only on you in case the state was notified. I will never do what my manager says without an MD order to back it up. I dont care how much she barks, unless she is gonna come and do it herself, I will be calling the doctor.

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