Resident Administered Insulin in Error
Penalty
Summary
A significant medication error occurred when a nurse administered a long-acting insulin to a resident who did not have a diagnosis of diabetes and was not prescribed insulin. Facility policy requires that medications be administered by licensed nurses as ordered by the physician, and that medications ordered for one resident are never administered to another. Despite these policies, the nurse gave the resident insulin at approximately 12:56 p.m., as later confirmed by the nurse's written statement and the Director of Nursing. The resident involved had a medical history including renal insufficiency, sepsis, and lymph edema, but no history of diabetes. The error was discovered after the resident's family reported the incident to nursing staff, and subsequent documentation confirmed the administration of insulin of an unknown amount. The Director of Nursing acknowledged that the facility failed to ensure residents are free from significant medication errors, as required by facility policy and state regulations.