Failure to Prevent Significant Medication Error in Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and severe cognitive impairment received insulin glargine injections despite physician orders specifying that the medication should not be administered if the resident's blood sugar was below 140. Documentation showed that the resident was given insulin on two occasions when their blood sugar levels were 118 and 126, both below the ordered threshold. The resident's care plan directed staff to administer medications as ordered and to report abnormal findings to the physician. Interviews with the DON and Administrator confirmed that staff were expected to follow physician orders and seek clarification if there was any uncertainty. Facility policy also required medications to be administered in accordance with written physician orders. Despite these expectations and policies, the insulin was administered outside of the prescribed parameters, resulting in a significant medication error.