Significant Medication Error Due to Improper Insulin Administration
Penalty
Summary
A registered nurse failed to properly verify and administer insulin to a resident with Type 2 Diabetes Mellitus and parkinsonism. The nurse administered 10 units of Novolog insulin using a pen that had expired beyond the manufacturer-recommended 28-day usage period. The nurse did not check the expiration date on the insulin pen prior to administration, as required by facility policy. Additionally, the nurse documented that Basaglar insulin was given, but in reality, Novolog was administered instead. Review of the resident's physician orders showed that Basaglar was to be administered once daily, and Novolog was to be given only per a sliding scale for elevated blood glucose levels. At the time of administration, the resident's blood glucose did not meet the threshold for Novolog per the sliding scale, and Basaglar was not available on the medication cart as required. Documentation revealed that Novolog had been administered multiple times without corresponding elevated blood sugar readings, and the nurse admitted to not following the physician's orders or verifying the medication label. The Director of Nursing confirmed these findings, resulting in a significant medication error.