Significant Medication Errors: Early Administration of Fast-Acting Insulin
Penalty
Summary
Surveyors found that the facility failed to prevent significant medication errors involving the administration of fast-acting insulin to three residents with diabetes. Nurses administered insulin lispro and insulin aspart to these residents more than one hour before their meal trays were delivered, despite manufacturer instructions and physician orders specifying that these medications should be given within 15 minutes before or immediately after a meal. Specifically, one resident received insulin 1 hour and 30 minutes before eating, another 1 hour and 28 minutes before, and a third 1 hour and 23 minutes before their meals arrived. All three residents had orders for sliding scale insulin to be administered before meals and at bedtime due to their diabetes diagnoses. Nurse interviews revealed that blood sugar checks and insulin administration were performed according to a scheduled time, without confirmation of when meal trays would actually be delivered. The nurse involved acknowledged that insulin should not have been administered more than 30 minutes before meals. The DON and Medical Director both confirmed that fast-acting insulin should be administered 15-30 minutes before meals and not before meal trays are present, as per facility expectations and standard practice. The administrator also confirmed that insulin should not be given until meal trays are in the vicinity.