Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of Type 2 Diabetes and Hypertension did not receive insulin as prescribed by the physician. The resident was ordered to receive Tresiba (long-acting insulin) 30 units subcutaneously at bedtime and Insulin Aspart (rapid-acting insulin) 10 units with meals. On the evening in question, the LPN responsible for medication administration was interrupted multiple times while preparing medications and subsequently administered the wrong type of insulin to the resident. The medication administration record indicated that the scheduled Tresiba dose was signed off as given, but the resident later experienced a significant drop in blood glucose levels, with readings as low as 70. The resident reported feeling unwell, and nursing staff documented a series of low blood sugar readings throughout the night, requiring interventions such as administration of cranberry juice and glucagon. The LPN later admitted uncertainty about which insulin was administered and recalled the error only after administering insulin to another resident. The incident was further corroborated by statements from the resident, who reported receiving the wrong insulin, and by the DON and physician, who both acknowledged the likelihood of a medication error based on the rapid decline in blood glucose. The facility's policy required prompt physician notification and monitoring for adverse consequences in the event of a medication error, which was not fully documented at the time of the incident.