Insulin Not Relabeled After Physician Order Change
Penalty
Summary
The facility failed to ensure that insulin medication for a resident with diabetes was properly labeled and stored according to current physician orders. Specifically, after a physician changed the resident's Novolin insulin order, the medication cart still contained insulin labeled with the previous dosing instructions. The label on the insulin pen reflected an outdated order, and the medication was not discarded or relabeled to match the new prescription. The nurse did not notify the pharmacy of the new order immediately, nor was a change of order label placed on the medication as required by facility policy. The resident involved had a history of diabetes and hypertension and was able to understand and make decisions. The resident required some assistance with daily activities but was generally able to communicate needs. The discrepancy was identified during an observation and interview with a nurse, who acknowledged that the medication should have been discarded or relabeled to prevent administration errors. The facility's policies required that only the pharmacy modify prescription labels and that outdated medications be removed and replaced when orders change, but these procedures were not followed in this instance.