Medication Error Rate Exceeds 5% Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with a calculated error rate of 5.88% based on 2 errors in 34 observed opportunities. During medication administration, a Licensed Practical Nurse (LPN) did not prime a resident's Humalog insulin pen prior to dialing the prescribed dose, contrary to facility policy and procedure. The same LPN also failed to prime the resident's Glargine insulin pen before administration and did not ensure the insulin pen was dated when opened, as required for tracking expiration. These actions were directly observed by the surveyor during the medication pass. Interviews with the LPN and the Unit Manager confirmed that insulin pens should be primed with 2 units before each use and dated upon opening, with the Unit Manager stating that insulin expires 28 days after being opened. The LPN demonstrated a lack of knowledge regarding the priming procedure, stating incorrectly that priming was not necessary. The surveyor verified these deficiencies through direct observation, interviews, and review of facility policy, resulting in the identification of two medication errors for the resident.