Failure to Administer Insulin as Ordered and Adhere to Medication Timing
Penalty
Summary
A significant medication error occurred when a resident with diabetes and hypertension did not receive their prescribed Humulin 70/30 insulin as ordered by the physician. The resident's orders specified 90 units of insulin to be administered at 8:00AM and 5:00PM, with blood sugars checked beforehand. On multiple occasions, the insulin was either administered late or not given at all. Specifically, the morning dose on one day was given over four hours late, and the evening dose on another day was omitted entirely due to the medication not being available from the pharmacy. Additionally, another morning dose was administered two hours late. Blood sugar readings at these times were significantly elevated, with values of 405, 420, and 549 mg/dl recorded. The resident's care plan included monitoring for signs of hyperglycemia and hypoglycemia, and the physician expected to be notified of any missed or late doses, which did not occur. Interviews with nursing staff revealed that medication administration was delayed due to following room order rather than medication timing, and that the pharmacy was not contacted in a timely manner to ensure insulin availability. The DON confirmed that there was no backup supply of Humulin 70/30 insulin in the facility and that nurses should have informed leadership if medications were not given on time. The physician stated it was unacceptable to administer 70/30 insulin after breakfast and expected to be notified of any missed or late doses, which did not happen. The resident and family also reported concerns about not receiving insulin before meals as ordered.