Incorrect Insulin Administered Due to Medication Verification Failure
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes and morbid obesity, who was cognitively intact, received the wrong type of insulin during medication administration. The resident had a physician's order for insulin aspart to be administered before meals for hyperglycemia, but instead, an LPN administered 5 units of Basaglar KwikPen, a long-acting insulin, in error. The medication administration record (MAR) incorrectly documented that insulin aspart had been given, and the LPN was unable to locate the prescribed insulin aspart in the medication cart, finding only Basaglar and insulin lispro pens available. The facility's policy required verification of the right medication, dose, route, time, and resident identity before administration, but these procedures were not followed in this instance. The LPN did not realize the error at the time of administration and only became aware after review and questioning by the surveyor. The incident was confirmed through observation, record review, and staff interviews, with the LPN acknowledging the mistake and the MAR's inaccuracy.