Significant Medication Error: Insulin Not Administered With Meal
Penalty
Summary
A deficiency occurred when a resident with diagnoses of arthritis, depression, and diabetes did not receive their prescribed insulin as ordered. The facility's policy requires that medications be administered by licensed nurses according to physician orders and professional standards, specifically following the six rights of medication administration. The resident had a physician order for eight units of Insulin Aspart to be administered subcutaneously with meals. However, during a medication pass observation, an LPN administered the insulin at 9:42 a.m., which was after the resident's breakfast tray had already been delivered at 7:55 a.m. The LPN acknowledged that the medication was given late and not in accordance with the order to administer it with meals. The Director of Nursing confirmed that the resident did not receive the medication as ordered, resulting in a significant medication error. This event demonstrated a failure to ensure that residents are free from significant medication errors, as required by facility policy and regulatory standards.
Plan Of Correction
Resident R36 was assessed by the RN. Resident R36 has had no ill effects due to the medication error. Employee E18 was re-educated on the Facility Medication Policy by the Director of Nursing. The Director of Nursing or designee will re-educate Licensed nurses on the Facility Medication Policy. The Director of Nursing or designee will audit 3 medication passes for 3 weeks. Then 2 medication passes weekly for 4 weeks. Results will be reviewed monthly by the Quality Assurance Committee.