Insulin Administered from Another Resident's Supply Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a nurse administered Insulin Lispro to a resident using an insulin pen labeled for a different resident. The resident, who had a diagnosis of Type 2 diabetes mellitus and was receiving insulin injections per physician's orders, did not have his prescribed Insulin Lispro available at the time it was due. The nurse, after checking the medication supply and finding none available for the resident, used another resident's insulin pen, labeling the cap with the intended recipient's last name and using a new pen needle. This action was observed during medication administration and confirmed during interviews with facility staff. Facility records showed that the resident's insulin was supposed to be delivered later that night, but the nurse proceeded to use the medication intended for another resident to avoid missing a dose. The facility's policy explicitly prohibits administering medications prescribed for one resident to another and borrowing medications between residents. The Director of Nursing and Regional Compliance Nurse acknowledged that the nurse should not have used another resident's medication and that procedures for medication ordering and administration would need review.