Failure to Ensure Safe Insulin Administration and Hypoglycemia Management
Penalty
Summary
A resident with end-stage renal disease and insulin-dependent type 2 diabetes mellitus experienced a significant medication error due to multiple failures in care planning, medication administration, and communication. The resident's care plan did not include specific interventions for the administration of glucagon during hypoglycemic episodes, nor did it address the resident's risk for refractory hypoglycemia, despite a prior hypoglycemic event. The facility also failed to ensure that the glucometer used for blood glucose monitoring was accurately tracking dates and times, and it did not associate blood sugar values with specific residents, leading to confusion in documentation and care. On the day of the incident, a nurse administered insulin at a time that did not correspond with the scheduled order, and subsequently gave two doses of insulin within a short period (1 hour and 18 minutes). The nurse did not document a critically high blood glucose value of 434 mg/dL, nor was the physician notified of this abnormal result. Additionally, the nurse did not use a Spanish language interpreter to communicate with the resident, who primarily spoke Spanish, when administering insulin. The resident reported that he attempted to refuse the insulin due to feeling unwell and having vomited, but the nurse proceeded with the administration regardless. Later, when the resident became unresponsive with a blood glucose level of 50 mg/dL, another nurse failed to administer glucagon as per facility protocol, citing inability to locate the medication and not considering the emergency kit as a resource. Instead, oral interventions were attempted, but the resident was unable to swallow. Emergency services were called, and the resident required life-saving treatment at a hospital. The sequence of events was compounded by incomplete and inaccurate documentation, lack of timely physician notification, and inadequate communication among staff.