Significant Medication Error Due to Missed Insulin Doses
Penalty
Summary
A resident with diagnoses including type 2 diabetes, cerebral infarction, dementia without behaviors, and atrial fibrillation was admitted to the facility with physician's orders for Insulin Glulisine to be administered three times daily per sliding scale. On one day, the resident did not receive any of the prescribed insulin doses, despite having elevated blood sugar readings between 240-365 that would have required insulin administration according to the physician's orders. The medication administration record confirmed that three doses were missed. Interviews with staff revealed that medications for new admissions typically arrive the next morning, and if a medication such as insulin is not available, the provider and pharmacy should be notified immediately. The LPN stated that the resident's insulin was not given due to insurance issues and that the provider should have been contacted for new orders. The DON indicated that prior authorization for medications is usually addressed before admission and was unaware of any such requirement for this resident. Facility policy requires that all medications be administered as ordered and that staff should check for misplaced medications and contact the pharmacy if a medication is unavailable. The failure to administer insulin and to communicate promptly with the physician constituted a significant medication error.