Failure to Prevent Significant Medication Errors in Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic neuropathy was administered insulin despite blood sugar levels being below the physician-ordered threshold for administration. The physician's order specified that insulin should be held if the capillary blood glucose (CBG) was under 150, and the physician should be notified if CBG was less than 70 or more than 360. However, medication administration records over a three-month period showed multiple instances where insulin was given when the resident's blood sugar was below 150, with values ranging from 86 to 149. The only incident report completed documented one such occurrence, but there was no evidence of adverse effects in the resident's progress notes. Interviews with nursing staff revealed a lack of awareness regarding the medication errors, with one LPN stating she did not realize the errors and an RN attributing the mistake to the way the order was written. The DON was not aware of the repeated errors and had not investigated further incidents beyond the one documented. The facility's medication administration policy required medications to be given according to physician orders as indicated on the electronic medication administration record, which was not followed in these instances.