Failure to Administer Insulin as Ordered Results in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that insulin was administered as ordered for two residents with diabetes, resulting in significant medication errors. For one resident, the care plan identified a risk for blood sugar alterations and required insulin administration before meals. However, the resident's electronic medication record showed that NovoLOG insulin, scheduled for 6:30 AM, was not administered until 9:19 AM, after the resident had already eaten breakfast. Additionally, the Basaglar insulin, also ordered for the morning, was not documented as given. Interviews with the LPN and DON confirmed that the insulin was not administered within the ordered parameters, and the resident confirmed not receiving insulin prior to eating. For the second resident, who also had a diagnosis of diabetes and was independent in daily activities, the treatment administration record indicated an order for Insulin Aspart to be given before meals at 6:30 AM. The electronic medication record showed that the insulin was administered at 7:58 AM, which was after the scheduled time. The LPN confirmed the late administration, and the DON verified that the insulin was not given as ordered. Observations confirmed that the resident was eating breakfast in the dining room during this period. Facility policies required insulin to be administered in accordance with physician orders, coordinated with mealtimes, and in compliance with the six rights of medication administration. Manufacturer guidelines for NovoLOG specified that the medication should be taken 5-10 minutes before eating. The failure to administer insulin as ordered and within the specified timeframes for both residents constituted significant medication errors, as confirmed by staff interviews and documentation review.