Resident Administered Wrong Medication After Refusal
Penalty
Summary
A resident with diagnoses including renal insufficiency, sepsis, and lymphedema was admitted to the facility and did not have a diagnosis of diabetes nor an order for insulin. Despite this, a registered nurse administered a long-acting insulin injection to the resident after the resident verbally refused the medication. The resident primarily spoke French and had limited English proficiency, which may have contributed to communication barriers. The nurse later admitted to the medication error, and documentation confirmed that the insulin was given against the resident's wishes. Facility policy required that if a medication dose is refused, the physician and responsible party must be notified, and the reason documented in a progress note. However, these procedures were not followed. Staff interviews revealed inconsistent practices for resident identification, with some staff unsure if all residents had ID bands and relying on photos in the computer or names on doors. The Director of Nursing confirmed that the facility failed to ensure residents were free from neglect and mistreatment by administering the wrong medication after refusal.