Significant Insulin Administration Error Resulting in Resident Harm
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple comorbidities, including diabetes mellitus type 2, was not administered insulin according to physician orders. The resident's order specified that ten units of Novolog insulin should be given with meals and held if the blood glucose (BG) level was less than 110 mg/dL. Despite this, the insulin was administered at a BG level of 97 mg/dL, which was below the hold threshold. This error resulted in the resident being found unresponsive with a BG of 37 mg/dL, displaying symptoms such as flushing, drooling, sweating, and moaning, and requiring emergency intervention and hospitalization for hypoglycemia. Further review revealed that the resident's insulin was only administered at lunch and dinner, not with all meals as ordered, from the time the order was written. This discrepancy was not identified during routine audits or after the resident's return from the hospital, despite the discharge order specifying insulin with meals three times daily. The error in administration times persisted for several months and was confirmed by staff interviews and review of medication administration records. The facility's policy required medications to be administered in accordance with prescriber orders, but this was not followed in the case of the resident's insulin regimen. The incident was documented in the facility's incident logs and medical records, and staff interviews confirmed the failure to adhere to the prescribed insulin parameters and schedule.