Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
A physician's order was in place for a resident to receive 7 units of Aspart insulin subcutaneously three times daily. On one occasion, the resident returned from dialysis and a blood glucose check was performed. The nurse on duty administered insulin but was unable to verify the amount given when questioned by the charge nurse and the resident. The resident reported being told by the charge nurse that the wrong amount was given, but neither the nurse on duty nor the resident could specify the exact dosage at that time. Further review and interview with the Director of Nursing Services confirmed that the resident was given 12 units of Humalog insulin instead of the ordered 7 units of Aspart insulin. The nurse on duty also informed the night charge nurse of the situation, and the resident expressed anxiety and requested additional blood glucose monitoring. The physician's order was not followed, resulting in the administration of the incorrect type and dosage of insulin.