Failure to Administer Insulin per Physician Orders and Manufacturer Instructions
Penalty
Summary
A deficiency occurred when staff failed to administer insulin according to the physician's sliding scale orders and manufacturer instructions for a resident with diabetes. The resident's care plan required staff to administer diabetes medication as ordered and to educate caregivers on correct glucose monitoring and insulin injection protocols. However, the sliding scale insulin order taped inside the resident's plastic supply bin was outdated and did not match the current physician's order in the electronic medical record (EMAR). On the day of observation, an LPN administered 2 units of insulin based on the outdated sliding scale in the bin, rather than the 3 units indicated by the current order and EMAR for the resident's blood sugar reading of 198. The LPN was unaware of the discrepancy and did not verify the dose with the EMAR before administration. Additionally, the LPN did not follow manufacturer instructions for using the Novolog insulin flexpen. The insulin pen was not primed prior to administration, and the LPN was not aware that priming was required to ensure the correct dose was delivered. The facility did not have a specific policy for insulin flexpen administration, and staff relied on both printed sliding scale orders in supply bins and the EMAR, leading to inconsistencies. Interviews with other nursing staff revealed varying practices, with some staff always checking the EMAR and others relying on printed orders in the bins, which were not always updated when orders changed. The Director of Nursing acknowledged that the process for updating sliding scale orders in the bins was not consistently followed, especially after recent order changes. The lack of a standardized process for ensuring that printed orders matched the EMAR, combined with insufficient staff education on insulin pen administration, contributed to the medication error. The facility's policy required medications to be administered as prescribed and for staff to verify orders, but this was not consistently implemented in practice.