Failure to Follow Insulin Administration Protocols Leads to Hypoglycemic Emergency
Penalty
Summary
A diabetic resident experienced a significant medication error when nursing staff failed to follow insulin administration instructions. On the day in question, the resident refused both breakfast and lunch, but was still administered scheduled doses of fast-acting insulins (Humalog and Fiasp) as documented in the Medication Administration Record. The instructions for Humalog specifically required administration with meals. The Certified Nurse Assistant documented the meal refusals and informed the nurse on duty, but the insulin was administered regardless. Later that day, the resident was found unresponsive with abnormal breathing, and emergency paramedics determined the resident's blood sugar was critically low at 22. Emergency interventions, including intravenous fluids and glucagon, were required, and the resident was transferred to the hospital for further evaluation. Interviews with staff revealed a lack of awareness and adherence to the facility's hypoglycemic protocol. One nurse stated she was not aware of the protocol, and another believed an active order for emergency glucagon was required for diabetic residents. The resident's care plan included monitoring and reporting signs and symptoms of hypoglycemia, but there was no active order for glucagon in the resident's records. Facility policies required verification of insulin orders and administration instructions, but these were not followed, resulting in the resident's hypoglycemic episode.