Failure to Administer Rapid-Acting Insulin According to Manufacturer Instructions
Penalty
Summary
A deficiency occurred when a resident with diabetes mellitus type 2, chronic kidney disease, heart failure, and other comorbidities was administered rapid-acting insulin (Fiasp insulin aspart) in a manner inconsistent with manufacturer instructions. The resident's medication administration record showed that the insulin was given significantly before the meal, with documentation indicating the injection was administered approximately 45 minutes prior to the resident receiving his meal. Manufacturer guidelines specify that Fiasp insulin should be given at the start of a meal or within 20 minutes after starting a meal. The consulting pharmacist and director of nursing both confirmed that the insulin was not administered according to these guidelines. On the day of the incident, the resident was found sweating and drooling, with altered mental status, after receiving his insulin but before eating. Blood sugar readings documented a drop from 99 mg/dL to 68 mg/dL, and upon arrival at the emergency department, the resident's blood sugar was 33 mg/dL. The resident had a recent history of influenza and poor oral intake, yet the facility continued to administer his usual insulin doses without adjustment or provider consultation. The nurse on duty attempted to treat the hypoglycemia with orange juice and sugar packets but did not follow the facility's standing orders for severe hypoglycemia, which required the use of glucagon gel or injection if the resident was unresponsive or unable to swallow. Interviews with nursing staff revealed uncertainty regarding protocols for insulin administration and hypoglycemia management. The nurse involved was unaware of the availability of glucagon injection in the emergency kit and did not follow the standing order protocol. Review of facility policies and staff files indicated gaps in annual competency assessments and a lack of clear policy guidance on following manufacturer instructions for insulin administration or managing diabetic complications. The facility assessment did not specify requirements for maintaining staff competency at least yearly.