F0760

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Significant Medication Error: Insulin Administered to Non-Diabetic Resident

Morganton, North Carolina Survey Completed on 04-24-2025

Penalty

Fine: $17,345

Summary

A significant medication error occurred when a nurse administered 30 units of insulin glargine, intended for a diabetic resident, to another resident who did not have a diagnosis of diabetes and no physician's order for insulin. The error took place in the dining room, where two residents were seated together, and the nurse failed to verify the correct identity of the resident prior to administration. The nurse immediately recognized the mistake after administering the insulin and reported it to the appropriate medical staff and the resident's family.

The resident who received the insulin in error was severely cognitively impaired and unable to communicate that she was not supposed to receive insulin. She was closely monitored following the incident, with hourly blood sugar checks and intravenous dextrose administered as ordered by the nurse practitioner. During the monitoring period, the resident's blood sugar dropped to 61, prompting further intervention, including administration of orange juice, a snack, and glucagon as ordered by the on-call provider. The resident remained alert and did not display signs of hypoglycemia during the observed period.

Interviews with nursing staff, the medical director, and the consulting pharmacist confirmed that administering a high dose of long-acting insulin to a non-diabetic resident could result in hypoglycemic events. The nurse involved stated that she was working on a hall she was not normally assigned to and attributed the error to failing to follow proper medication administration protocols, specifically not verifying the resident's identity and administering medication outside of the resident's room. The director of nursing and administrator both stated their expectation that staff follow the six rights of medication administration, which were not adhered to in this incident.

Removal Plan

• Nurse #1 was suspended pending investigation.
• The Director of Nursing contacted the Board of Nursing regarding the medication error.
• The Provider immediately assessed Resident #16 and gave orders for hourly blood sugar checks, IV dextrose, and monitoring for hypoglycemia.
• Resident #16's Responsible Party was notified of the medication error.
• The Director of Nursing and/or Designee reviewed finger stick blood glucose levels of all residents requiring glucose monitoring to ensure no signs of hypoglycemia.
• The Director of Nursing and/or Designee audited residents with active orders for blood glucose monitoring and insulin to ensure insulin was administered per orders.
• The Director of Nursing interviewed cognitively intact residents and assessed cognitively impaired residents for signs of hypoglycemia.
• Education was started for all Licensed Nurses and Medication Aides (including agency staff) on not administering medications in the dining room and to follow the 6 rights of medication administration, including verifying resident identity using the electronic health record picture.
• Licensed Nurses and Medication Aides not currently working were educated via phone or in person and will not be allowed to work until they have received this education.
• Any Nurse on leave or paid time off will be provided the education prior to working their next shift.
• Education will be provided in new hire orientation for all Licensed Nurses and Medication Aides.
• Agency credentialing/education specialists were contacted and provided the facility-specific plan of correction education packet; agency staff must receive this education before working in the facility.
• The Director of Nursing educated the Scheduler on ensuring continuity of staff assignments to prevent medication errors.
• The Director of Nursing and/or Designee will observe 3 medication passes for Licensed Nurses and/or Medication Aides weekly for 8 weeks, then monthly for 1 month, to ensure medications are administered as ordered.
• The Director of Nursing and/or Designee will observe 5 residents in the Dining Room weekly for 8 weeks, then monthly for 1 month, to ensure no medications are being passed in the dining room.
• An ADHOC QAPI meeting was held to discuss the incident and educate the team on interventions.
• The Medical Director was notified of the medication error and interventions.
• The Interdisciplinary team will review and provide recommendations on audit results during QAPI meetings for the next 3 months to ensure sustained compliance.
• If noncompliance is identified, immediate correction, re-education, and an ADHOC QAPI meeting will be held to address and adjust the plan.
• The Administrator and Director of Nursing will ensure the corrective action plan is implemented.