Significant Medication Errors Involving Insulin Overdose and Missed High-Alert Medications
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed for two residents, resulting in significant medication errors. One resident with diabetes and end-stage kidney disease received an injection of Lantus insulin that was 7.2 times their prescribed dose, which was intended for a different resident. This error occurred when a recently licensed LPN, who was still orienting, administered the pre-drawn insulin syringe to the wrong resident after becoming confused during a simultaneous medication pass for multiple residents. The resident experienced an extended period of symptomatic hypoglycemia, requiring rescue medications on five separate occasions to normalize blood sugar levels and symptoms. Documentation of the administration of rescue medications and adherence to the hypoglycemic protocol was incomplete in the medical record. Another resident, who was cognitively intact and had diagnoses including diabetes and atrial fibrillation, did not receive their ordered doses of an anticoagulant (Xarelto) and an injectable medication (Ozempic) used to manage weight and blood sugar. The MAR indicated that the anticoagulant was marked as not available due to a pharmacy backorder, despite the medication being present in the facility's emergency stock. There was no documentation of staff efforts to procure the medication or notify the provider of the missed dose. Additionally, the resident missed multiple scheduled doses of Ozempic due to delays in medication procurement and lack of clear communication regarding the medication's source and billing, with no documentation explaining the missed doses in the progress notes. Interviews with staff revealed gaps in orientation, competency verification, and communication regarding medication administration and error reporting. The LPN involved in the insulin error had not received a medication competency checklist until after the incident and was primarily performing tasks outside the LPN role during orientation. Nursing leadership acknowledged that high-alert medications like insulin and anticoagulants require careful monitoring and reporting, but reviews and follow-up on missed doses were inconsistent or absent. The provider was not fully informed of the extent of the resident's hypoglycemic episodes and rescue interventions.