Failure to Timely Reorder Insulin Medication
Penalty
Summary
The facility failed to provide timely insulin medication for a resident, leading to a deficiency in pharmaceutical services. The resident, a male with multiple health conditions including diabetes mellitus, was admitted to the facility and required regular insulin administration. On a specific day, a Licensed Practical Nurse (LPN) discovered that the resident's prescribed Lispro insulin was not available in the medication cart or the emergency kit. Despite contacting the physician and placing an order with the pharmacy, the insulin was not delivered in time, and the resident's blood glucose levels had to be monitored hourly until the medication arrived. The Unit Manager and Director of Nursing (DON) acknowledged that the insulin should have been reordered before the supply was depleted. The facility's guidelines required nurses to reorder medications electronically or through other means to ensure timely delivery. However, the insulin was not reordered in time, resulting in a lapse in the resident's care. The facility's standards also indicated that in cases of medication shortages, nurses were expected to use the emergency supply or arrange for an emergency delivery, which was not effectively executed in this instance.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On DON ordered from the pharmacy STAT for resident number 93. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Audit completed on residents who require to ensure is available. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee to complete education with Licensed Nurses to ensure residents who receive have on. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete audit of residents who received to ensure is available and or for ordered use ensure compliance with federal regulation F755 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk Management meeting until such time substantial compliance has been determined.