Insulin Administered from Another Resident's Supply
Penalty
Summary
A registered nurse prepared and administered insulin to a resident using a multi-dose vial that belonged to a different resident. The nurse did not compare the scheduled medication with the medication label prior to administration, as required by facility policy. When questioned, the nurse stated that it was acceptable to borrow medication from another resident, especially since the original resident needed to leave for dialysis. Further interviews with facility leadership confirmed that staff are instructed not to use medications belonging to other residents and should instead use the convenience box if a medication is not available in the medication cart. The affected resident had a diagnosis of Type 2 Diabetes Mellitus and was ordered to receive Insulin Lispro as per a sliding scale. Facility policy requires verification of the five rights and comparison of the medication and dosage schedule on the MAR with the medication label prior to administration, which was not followed in this instance.