Medication Error Rate Exceeds Acceptable Threshold Due to Insulin Pen and Order Verification Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with surveyors observing a 13.33% error rate during medication administration. Thirty medication opportunities were observed, and four errors were identified involving residents with complex medical histories, including diabetes, anemia, and vitamin D deficiency. Specific deficiencies included staff failing to prime insulin pen injectors before administration, as observed with multiple residents receiving insulin. In one instance, a registered nurse administered insulin without priming the pen, stating, "I don't do that" when questioned. In another case, an LPN also failed to prime the insulin pen for two different residents, later admitting to forgetting this step. These actions were in direct violation of the facility's insulin pen administration policy, which requires priming prior to each use to prevent air collection in the reservoir. Additionally, a medication was administered to a resident after the order for that medication had been discontinued, as confirmed by review of the medication administration record and facility orders. The facility's policies require staff to verify medication, dose, route, rate, time, and resident identity prior to administration, but these procedures were not consistently followed. The Director of Nursing acknowledged awareness of the errors and confirmed that staff had recently received training on insulin administration, which included the requirement to prime pens, but staff did not adhere to this protocol during observed medication passes.