Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to administer insulin as ordered by physicians for four residents with diabetes, resulting in significant medication errors. On May 17, 2025, there was a gap in nursing coverage when the day shift nurse left at approximately 3:00 PM and the evening shift nurse did not arrive until 5:45 PM. During this period, no other staff were assigned to administer medications, leading to delays in scheduled insulin administration. Residents reported not receiving their medications on time, and electronic medical records confirmed that insulin doses scheduled for the evening meal were administered several hours late. For example, one resident with multiple chronic conditions, including diabetes and heart failure, received their scheduled 5:00 PM insulin dose at 9:14 PM, more than four hours after dinner. Another resident, also with diabetes and other comorbidities, received their 5:00 PM insulin at 6:50 PM and their 4:00 PM sliding scale insulin at 6:50 PM, both significantly delayed. A third resident with moderate cognitive impairment received their 5:00 PM insulin at 9:09 PM, and a fourth resident received their 5:00 PM insulin at 8:42 PM. In all cases, the insulin was ordered to be given with meals or at specific times, but was not administered as scheduled. The facility's own policies require medications and treatments to be administered according to physician orders and federal and state regulations. The pharmacist confirmed that the types of insulin involved are intended to be given with meals or at specific times to maintain stable blood glucose levels, and that significant delays can cause blood sugar fluctuations. The failure to follow physician orders and facility policy resulted in significant medication errors for multiple residents.