Medication Error Rate Exceeds Acceptable Threshold Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During a review of medication administration, two errors were identified out of 29 opportunities, resulting in a 6.9% error rate. Specifically, a resident with diagnoses including type two diabetes mellitus, generalized anxiety disorder, and peripheral vascular disease was involved. The resident had intact cognition and required staff assistance with activities of daily living. On the observed date, an LPN administered 22 units of Humalog insulin and 54 units of Glargine insulin to the resident without priming the insulin pens prior to administration. The LPN confirmed in an interview that she did not perform the priming step. Manufacturer guidelines for both types of insulin require priming the pen before each injection to ensure proper dosing and function. Failure to follow these guidelines led to the medication administration errors identified during the survey.