Insulin Administered at Incorrect Time Without Meal
Penalty
Summary
A significant medication error occurred when a resident with Type 2 Diabetes Mellitus was administered rapid-acting insulin (Insulin Aspart) at an inappropriate time. The medication label and physician orders specified that the insulin should be given before meals, but the nurse administered the insulin without ensuring the resident was about to eat or providing food. Observations confirmed that no food was present in the resident's room at the time of administration, and the resident had not eaten following the injection. The resident later reported feeling tired and stated that insulin is usually given approximately 30 minutes before meals, but on this occasion, it was given earlier than usual without a meal following. Interviews with facility staff, including the DON, the nurse involved, and the pharmacist, confirmed that the insulin was administered too early and not in accordance with the facility's policy or the physician's orders. The facility's policies on medication and insulin administration emphasize the importance of timing, particularly for rapid-acting insulin, which has an onset within 15 minutes and peaks within 0.5-1.5 hours. The failure to coordinate insulin administration with meal timing placed the resident at risk for complications associated with hypoglycemia.