Medication Administration Error: Insulin Borrowed Between Residents
Penalty
Summary
Nursing staff failed to meet professional standards of quality by administering medication intended for one resident to another. Specifically, a Licensed Practical Nurse (LPN) was observed withdrawing regular insulin from a vial labeled for one resident and administering it to a different resident. The facility's policy clearly states that medications ordered for a particular resident may not be administered to another resident unless permitted by state law, facility policy, and approved by the Director of Nursing Services. The LPN acknowledged that the insulin vial used belonged to a different resident and confirmed that the correct insulin vial for the intended recipient was available in the medication room at the time. The incident involved two residents, both with Type 2 Diabetes Mellitus and individual physician orders for regular insulin with specific sliding scale instructions. The LPN did not follow the required procedure of verifying the correct medication for the correct resident, as outlined in the facility's medication administration policy. The Director of Nursing confirmed that each resident had their own insulin vial and that emergency stock was available if needed, emphasizing that staff should not use one resident's medication for another.