Incorrect Insulin Administered Due to Medication Error
Penalty
Summary
Facility staff failed to administer the physician-ordered medication for a resident who required assistance with medication administration. The resident, admitted with diagnoses including acute respiratory failure with hypercapnia, muscle weakness, dysphagia, Type II Diabetes Mellitus, hypertension, and atherosclerotic heart disease, had a physician order for Insulin Aspart U-100 to be given subcutaneously before meals, with specific instructions to hold if blood sugar was less than 150. Review of the medication administration record showed staff documented administration of Insulin Aspart as ordered. However, observation of the medication cart revealed that an open and used Insulin Lispro pen, not Insulin Aspart, was present and had been used for this resident. The Assistant Director of Nursing confirmed that the Insulin Lispro pen belonged to the resident and had been used to provide insulin, despite no physician order for Insulin Lispro.