Significant Medication Error: Insulin Administered Without Food for Diabetic Resident
Penalty
Summary
A resident with diabetes, who required set up assistance for eating and received daily insulin injections, was administered 3 units of lispro insulin at 7:00 AM based on a sliding scale after a glucose check showed a level of 196 mg/dL. Facility policy required that medications ordered before or after meals be given in correct relation to meals. However, the resident was scheduled for an outside appointment that morning and did not receive breakfast prior to leaving. The resident's breakfast tray was observed untouched later that morning, and there was no documentation of breakfast intake. Interviews with staff revealed inconsistent practices regarding meal provision for residents with early appointments, with some staff unaware of the need to provide food for diabetic residents who received insulin. The resident reported not eating before the appointment and required their daughter to obtain food from a vending machine during the appointment. Staff interviews confirmed that no food was sent with the resident, and there was no established process to ensure meals were provided in such situations, leading to the resident being at risk after receiving insulin without food.