Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that six out of seven sampled residents were free from significant medication errors, specifically related to the administration of insulin and other diabetes medications. Multiple residents with diabetes mellitus, some with additional conditions such as chronic kidney disease or cognitive impairment, did not receive their prescribed insulin regimens as ordered by their physicians. The errors included late administration, omission of doses, and administration of incorrect dosages. For example, one resident received insulin glargine when it should have been held due to a low blood glucose level, and there was no documentation that the physician was notified. In several instances, the medication administration records (MARs) were incomplete or lacked explanations for missed or late doses, and progress notes did not document reasons for deviations or physician notifications. Residents reported receiving their insulin and other medications late, sometimes after meals when they were ordered to be given before or with meals. Some residents expressed feeling unwell as a result, describing symptoms such as feeling "crappy," tired, dizzy, or sick. Staff interviews confirmed that insulin was often administered outside the prescribed timeframes, and that documentation practices were inconsistent, with some nurses recording administration times that did not reflect when the medication was actually given. The Assistant Director of Nursing acknowledged that medication auditing had only recently begun and that prior auditing practices were unclear. The facility's policies required medications to be administered as prescribed, with specific timing for medications ordered with meals, and for documentation to occur at the time of administration. However, these policies were not consistently followed. Staff interviews further confirmed that late or missed insulin administration could result in significant health risks for residents, and that the practice of documenting medications at times other than when they were actually given could lead to medication errors. The facility's failure to administer medications as ordered and to document appropriately resulted in significant medication errors for multiple residents.