Failure to Administer Insulin Due to Staff Unawareness of Emergency Stock
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus did not receive a prescribed dose of Humalog insulin as ordered by their physician. The resident's blood sugar was measured at 229, which required 4 units of Humalog insulin according to the sliding scale order, but the medication was not administered. The nurse documented that the Humalog was not in the facility at the time. However, subsequent review and interviews revealed that the resident's insulin pen was available, and emergency stock of Humalog insulin was also present in the medication room. The resident had recently been transferred to a different hall, but both the resident's insulin pen and emergency stock were accessible on the new hall. Further investigation showed that the nurse responsible for administering the medication was new and on her first shift off orientation. She was unaware of the availability of emergency stock insulin and was advised by another nurse to document the medication as unavailable. Later that evening, after being informed about the emergency stock, the nurse administered the required insulin dose when the resident's blood sugar had increased to 317. The Director of Nursing confirmed that the facility's expectation is to use emergency stock if a resident's insulin pen is not available, and not administering insulin as ordered is considered a significant medication error.