Failure to Administer Insulin at Correct Times Results in Elevated Medication Error Rate
Penalty
Summary
The facility failed to ensure that medications, specifically rapid-acting insulin, were administered at the correct times for two residents diagnosed with Type 2 Diabetes. Observations and record reviews revealed that insulin was routinely given after meals rather than within the recommended timeframe before meals, as outlined in both facility policy and manufacturer instructions. For one resident, insulin was administered over an hour after breakfast, and for another, insulin was given nearly two hours after the scheduled time and after lunch. Both nurses involved confirmed during interviews that their usual practice was to perform blood glucose checks before meals but to administer insulin after the residents had eaten. These actions resulted in two medication errors out of 25 observed opportunities, leading to a medication error rate of 8%, which exceeds the acceptable threshold of less than 5%. The Director of Nursing confirmed that such insulin administration errors are considered significant and that insulin should be given as ordered and before meals. The facility's failure to adhere to its own policies and accepted standards for timely medication administration directly contributed to the identified deficiency.