Failure to Prevent Significant Medication Errors in Diabetic Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving residents with diabetes. For one resident admitted with multiple diagnoses including type 2 diabetes and an unstageable pressure ulcer, physician orders required blood glucose monitoring at four specific times daily and administration of sliding scale insulin based on results. However, there was no documentation that blood glucose was checked at all on one day, and on three subsequent days, it was only checked once daily at night. The Director of Nursing confirmed that glucose monitoring and insulin coverage were not provided as ordered during this period. In another case, a resident with diabetes and a recent femur fracture was observed receiving insulin from an RN who failed to prime the insulin pen prior to administration. Manufacturer guidelines for the insulin pen require priming before each injection to ensure accurate dosing. The RN acknowledged not priming the pen, which could result in the resident receiving an incorrect dose of insulin. These findings were substantiated through observation, record review, staff interview, and reference to manufacturer instructions.