Missed Timely Administration of Insulin Dose
Penalty
Summary
A resident with a history of cerebral infarction, hemiplegia, and diabetes was admitted and readmitted to the facility, requiring insulin for diabetes management. The resident's care plan specified insulin dependence and directed staff to administer hypoglycemic medications as ordered. The resident was assessed as having moderately impaired cognition and was dependent on staff for daily activities. On review of the Medication Administration Record (MAR), it was found that the resident's scheduled dose of Lispro, a fast-acting insulin, was not administered at the prescribed time. During an interview and record review, an LVN confirmed that the Lispro dose, scheduled for 1:00 p.m., was not given because the nurse was busy. The MAR indicated the missed dose by displaying it in red, which the LVN explained signified a late or omitted medication. Facility policy required medications to be administered within one hour of the scheduled time, but this was not followed. The LVN acknowledged that this constituted a medication error and that timely administration was necessary according to the prescriber's order.