Failure to Document and Properly Administer Insulin Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration and documentation of insulin for residents with diabetes. Staff did not document the administration of insulin or the checking of blood sugar levels for two residents over multiple days, as evidenced by blank entries in the Medication Administration Records (MARs) despite active physician orders for both blood glucose monitoring and insulin administration. Interviews with staff and leadership confirmed that if the MAR is blank, it is assumed that the medication or task was not completed, which constitutes a medication error. The Medical Director also confirmed that undocumented insulin administration is considered a significant medication error. Additionally, staff failed to follow manufacturer guidelines for insulin pen use by not priming the pens prior to each administration for two residents. Observations showed that registered nurses administered insulin using prefilled pens without priming them, contrary to both facility policy and manufacturer instructions, which require priming before every use to ensure accurate dosing. Interviews with nursing staff revealed a lack of awareness regarding the need to prime insulin pens with each use, with some staff believing priming was only necessary for new pens. Leadership, including the DON, Administrator, and Corporate Nurse Consultant, stated that priming is required every time, as per manufacturer guidelines. The residents involved had diagnoses of Type 2 diabetes and were cognitively intact or severely cognitively impaired, depending on the individual. Their care plans and physician orders required regular blood glucose monitoring and insulin administration, including sliding scale dosing. The failure to document administration and to properly prepare insulin pens directly contradicted facility policy and physician orders, resulting in significant medication errors for multiple residents.