Failure to Prevent Significant Medication Errors in Insulin and Oral Medication Administration
Penalty
Summary
Surveyors identified that licensed staff failed to rotate subcutaneous insulin injection sites for three residents with diabetes, despite physician orders and facility policy requiring site rotation. Documentation showed repeated administration of insulin in the same anatomical areas over extended periods. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed during interviews that this practice did not comply with professional standards, facility policy, or prescriber orders, and constituted a medication error. Additionally, surveyors observed medication administration errors involving the preparation and timing of medications for residents with kidney disease and diabetes. One nurse prepared Lokelma for a resident using significantly more water than prescribed, based on the resident's preference, without obtaining a physician order or updating the care plan. The same nurse also administered sevelamer outside of mealtime, contrary to the prescription and pharmacy label instructions. The nurse acknowledged these deviations and the potential for incomplete dosing or reduced medication effectiveness. Further observations revealed that metformin and potassium chloride were administered to residents without food, despite explicit physician orders to give these medications with meals. There were also missed doses of hydrocodone/APAP for two residents. These actions were confirmed by staff interviews and record reviews as not being in accordance with physician orders or accepted professional standards, and were recognized by facility leadership as medication errors.