Failure to Administer Insulin as Ordered Before Meals
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors related to insulin administration for two residents with Type 2 Diabetes. Facility policy and insulin manufacturer guidelines require that rapid-acting insulin, such as Novolog (Insulin Aspart), be administered within 15 minutes before a meal. However, observations and record reviews revealed that both residents received their insulin after meals, contrary to physician orders and best practice guidelines. For one resident, insulin was administered over an hour after the scheduled time and after the resident had already eaten lunch. For the other resident, insulin was given after breakfast, despite the blood sugar check being performed before the meal. Interviews with nursing staff confirmed that it was their usual practice to administer insulin after meals, rather than before as required. The Director of Nursing also acknowledged that these instances constituted significant medication errors and that insulin should be administered as ordered and prior to meals. The facility census at the time was 50, and the findings were based on direct observation, record review, and staff interviews.