Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of one resident who was administered incorrect doses of insulin on multiple occasions. The facility's policy required that medications be administered as ordered by the physician, ensuring the right resident received the right medication at the right time. However, a review of the Medication Administration Record (MAR) for the resident revealed several instances where the insulin dosage administered did not match the physician's orders. Specifically, the resident was given higher doses of insulin than prescribed on several dates, and insulin was administered when it should have been withheld according to the sliding scale instructions. The resident in question was cognitively intact and required assistance for care needs, with a diagnosis of Type I diabetes, necessitating careful management of blood sugar levels through insulin administration. The physician's orders included a specific sliding scale for insulin administration before meals and at bedtime, with different dosages based on blood sugar readings. Despite these clear instructions, the facility's staff failed to adhere to the prescribed dosages, leading to significant medication errors. The Director of Nursing confirmed that the insulin was not administered as ordered by the physician on the specified dates.
Plan Of Correction
1. Facility did not identify any additional residents with dose administration errors. 2. On the spot education initiated on 4/18/2025 for Registered nurses and Licensed practical nurses that reviewed the format of insulin administration orders and the need to read entire order because administration doses can vary at different administration times. 3. Further investigation identified root cause of error as nurse clinical judgement to administer the AC (before meals) dosage because insulin was being administered with evening snack. All errors made by the same licensed practical nurse. 4. Individual education completed on proper usage of AC (before meals) and HS (at bedtime) terminology with employee who made the administration dose error on 4/28/2025. 5. Facility initiated additional on the spot education on 5/6/2025 to all registered nurses and licensed practical nurses reviewing the definition of HS and AC and proper use of terminology. Education will be completed by 5/27/2025. 6. Director of Nursing will complete weekly dose administration audits on insulin administration given by employee who made the administration error. Audits will be completed weekly for 4 consecutive weeks then monthly for 2 consecutive months. 7. Director of Nursing will complete random insulin dose administration audits monthly for 3 consecutive months. 8. Results of audits will be reported at the Quality Assurance and Performance Improvement meeting.