Failure to Ensure Timely Insulin Delivery Due to Poor Pharmacy Collaboration
Penalty
Summary
A deficiency occurred when the facility failed to collaborate effectively with the pharmacy to ensure a new admission received prescribed insulin, resulting in the resident missing four days of medication. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and morbid obesity, was discharged from the hospital with an order for Humulin R U-500 insulin. Upon admission, a physician's order was entered for this medication, but due to its unusual concentration, the pharmacy required clarification before filling it. Subsequently, the order was changed to Humulin-R 100 units/mL, but the pharmacy did not fill this new order, and the medication was not available for administration on multiple days. Review of the Medication Administration Record (MAR) showed that the insulin was not administered on four separate days, and there was no documentation that nursing supervisors, providers, or the pharmacy were notified of the missed doses. Interviews revealed that the pharmacist was unaware of the new order and did not fill it, while the Director of Nursing stated that nursing staff should have followed up with the pharmacy each time the medication was unavailable. The lack of communication and follow-up led to the resident missing critical doses of insulin.