Insufficient Nursing Staff Leads to Missed Insulin Doses
Penalty
Summary
The facility failed to ensure sufficient nursing staff were present to meet the needs of all residents, resulting in significant medication errors for two residents with diabetes. On the morning in question, two of three assigned staff members, a Medication Aide and a Unit Manager, did not report to work as scheduled. This left only one nurse on duty for the three units, and the absence of staff was not promptly addressed, leading to a delay in medication administration. As a result, two residents who required scheduled morning doses of rapid-acting insulin did not receive their medication as ordered. One resident, who was cognitively intact, reported not receiving his insulin after breakfast due to the absence of the assigned staff member. The other resident, who had severe cognitive impairment, also missed the scheduled insulin dose. The Medication Administration Records confirmed that the insulin was not administered, and notes indicated the missed doses were due to overlapping doses from late administration, with the physician being made aware. Interviews with staff revealed that the scheduler was aware of the staffing shortage early in the shift and attempted to find replacements but was unsuccessful. The previous DON and other nursing staff arrived later in the day, but by that time, the morning medications had already been missed. Communication lapses among staff contributed to the delay in addressing the staffing issue, and the absence of key personnel directly led to the failure to administer critical medications as scheduled.