Request for assistance-need some people who have been around the diabetic block to give advice

80 YO female, has been insulin dependent for 18 years
was taking novalin, twice daily once before breakfast and the second time right before bedtime (4-6 cc each time) also takes micronease with each meal

suffers a fall and trapped on floor for eight hours, when found she is taken to emergency room where she is admitted to the hospital to be treated for for a severe urinary rack infection, given catheter for 5 days until deemed medically stable and then sent to “rehab facility” to regain strength to walk again

upon arrival at “rehab center” read old folks home, doctor at facility is told about her current medical regime of Novalin and micronease. Doctor ignores this and puts her on novalog three times a day right before meal as well as at bed time. The only reason I say nothing is that for the first time in a week I see my mom with a smile on her face, and she is happy with the staff etc.

currently taking 12-18 units daily

each test before meal blood sugar is in 200-350 range

son talks to doctor asks # of insulin treatment prescribed, he say three, once b4 each meal. Son returns to home, asked nurse at home and told 4 times, last time being right before bed. Son goes back and asks doctor again and he says yes only three and when told she is getting four times a day he says that I must be mistaken and he would call nurse to follow up on, but he never does.

when I finally tell the nurse this she becomes indignent and calls up doctor herself, comes by my moms room and says OK, the doctor said only three times a day before meals as previously discussed.

I ask the nurse why even in the documentation that comes with novolag in every package it says that novalog is to be used in conjunction with a long lasting insulin as part of a diabetic treatment regime, and why was she receiving no long lasting.

Her response was well we don’t know her so… but she readily agrees that just giving her novalog is just playing ping pong with her blood sugar level as novalog is only effective for 3-5 hours, and they are testing her blood sugar before each meal, which is roughly 5 hours apart so of course the readings are on the high side

told next night at bed told that they start to give my mom lantus (long lasting insulin) at bed time

next day discuss case with head nurse at home, she pulls chart notices that the doctor put in chart on 9.12 patient is to receive NO long lasting insulin
on 9.13 day after I talked to the other nurse about her insulin regiment, he now prescribes lantus at bedtime

mother given blood tests on 9/12, results come back with her HgbA1c rating coming back at 12.6 which I know is BAD

but here is the thing, she had the exact same blood work done on her right before she fell (on 8/20) and the number was still too high, but it was 9.4,
so in the course of three weeks that number has risen by over three points.

Here are my questions for you guys and in advance want to say thank you for any advice/insight you could offer me to understand what was/is going on here.

  1. Is there ever any sort of insulin regiment that runs on only novalog that is not a pump related treatment?
    or in other words what was the doc thinking in putting that note in chart saying no long lasting insulin is to be given to her.?

  2. Couldn’t the increase in the HgbA1c from 9.4 to 12.6 be directly attributed to her new insulin regime of novalog only,? and either way isn’t it a baromoter on the quality of care she is getting by both the home and especially the doctor?

Guys in advance I thank you from the bottom of my heart for any insight you can offer.

  1. Most people take both a long acting insulin in conjunction with short acting to gain control. Sounds like even before the fall, your mom’s diabetes was not under control. 9.4 is already dangerously high, 12.4 is even worse. Can you get her to an endocrinologist? Even the most conservative doctors try for an AIC of around 7 and lower is even better. Do you have a glucose monitor to test before and after meals? 200 plus before meals is dangerously high and will cause damage. You need to be aiming at under 140 AFTER meals, but this should be done gradually as it can be a huge shock to the system.

  2. Yes, the increase in the A1C is probably directly related to the insulin regime, but the one she was on before was also inadequate. Can you have her change doctors, as clearly this one does not understand even the basic minimum of diabetes care?

Good luck with all this, is must be very hard, but keep fighting for better care for your mom. She deserves it!

A question, how much longer do they say your Mom needs to be in this nursing facility? Unfortunately what most people don’t know is that these types of “homes” don’t like to have to give insulin to patients. And if they do they try to keep them a “little” on the high side so they don’t have to be checked so often and be treated for a low. Now I know you are most concerned about the diabetes, but this obviously is not the only very serius problem your Mom has. The doctor taking care of her before the fall was not doing an adequate job or her A1c would not have been so high, nor would the urinary tract infection have been so bad. You also need to find out why she fell. Was she dizzy? How is her blood pressure? Her heart also needs to be checked. I don’t want to scare you, but 80 really isn’t that old anymore. I would suggest you get a good GP for her and follow Libbly’s advice about an endo and get her diabetes under better control. It may be that she can do as well at home with a nurse coming in and a physical therapist Strangely enough these can even be much cheaper than a nursing or rehab facility. If this isn’t workable I would check to see if she needs to be back in the hospital until things are in better shape. Also there are retired nurses that may be able to provide nursing day care at home. There are a lot of options to check out, but a really good physical and workup would probably be in her best interest right now.
As far as why didn’t the doc do this or that until after talking to the nurse really doesn’t matter anymore. I would be more interested in what they are going to be doing for her now that they know you are not going to be sitting back and letting things just run a course. If no better care is being given, then I would be looking at a different facility or some of the suggestions I have made.
I am really glad to see you taking such an interest in all that is going on. And i don’t mean that in a silly way. Sometimes people just trust because they are so relieved that Mom is in a place to be taken care of and don’t understand the dangers loved ones can face. Good luck and please come back and let us know what is going on. As you can see we will be happy to give all the support you need. My prayers will be with you and your Mom.

In my experience, some physicians treat the “elderly” very gingerly, no matter how sharp they are. Especially after a fall. Is this physician her usual primary care physician? And if not, is there a reason her usual physician is not involved in her care at this point? Perhaps a call from him/her to her treating physician in the “rehab” would fix this issue. It is unfortunate, but there are many doctors out there that have their own beliefs about treating patients and not all of them are on the same page. I work as an outcomes analyst and see many doctors’ treatment plans and notes throughout the year in my travels. If this were my mom I would make sure to have a “sit down” with the treating physician to discuss the “long term” plan for mom and to get answers as to why a long acting insulin is not being used as she was using prior to her illness. As long as she is eating and has an appetite i see no reason why they should not be using it… with the novolog as a meal time coverage.
I hope all goes well…

Reading your story about your mother brought so many bad memories of what I went through when my mother was in a nursing home. I guess it isn’t necesary to go into all the sordid details. However, I so dismayed by the care she received, that I spent every waking moment I could at the nursing home and wound up sheparding many of the other residents.
One of the problems Is most nursing homes are owned my physicians who use these facilities as a cash cow. They hire the cheapest labor possible and are given a three day course for their nurse aid certification. The nurses are usually LVN’s.
I’ve sensored a lot of what I really want to tell you because I don’t want to scare you too badly. and there are good homes out there, but they’re hard to find. Needless to say, YOU have certain rights in your mothers care. find a physician/endo who will be willing to advise you and insist the nursing home follow his instructions. find out who the regulatory agency is in you state and get emails, web sites, and phone numbers. Get to know each and every nurse aid and nurse attending to her. Maintain as much presence as possible and if you have siblings try to maintain spot checks at the least.

If I can be of further service please don’t hesitate to ask. Best of luck to your mother and yourself.

Has anyone taken into consideration that she is under stress from the fall? Your diabetes educator will tell stress does effect your blood glucose, and not in a good way. I do agree that she should be on a long-acting insulin, though.