Failure to Notify Resident of Significant Medication Error
Penalty
Summary
The facility failed to notify a resident of a significant medication error involving the administration of a double dose of insulin lispro, which resulted in a hypoglycemic episode. The resident, who has Type 1 diabetes and is her own healthcare decision maker, was scheduled to receive 12 units of insulin lispro at two separate times in the morning. However, two licensed nurses administered the doses only 1 hour and 24 minutes apart, and an additional sliding scale dose was also given, totaling 27 units of fast-acting insulin. This led to the resident experiencing a dangerously low blood sugar level of 43 mg/dl, as documented in the medical record and confirmed by staff interviews. Despite the occurrence of this medication error and the resulting change in the resident's condition, the facility did not inform the resident about the error. Interviews revealed that the resident was not told about the double dosing incident and expressed a desire to have been notified. The facility's own policies require prompt notification of residents and their representatives regarding significant changes in condition or medication errors, but this was not followed in this case. Staff interviews further confirmed that the resident was not made aware of the medication error at the time it occurred.