Failure to Prevent Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin for two residents with diabetes. Facility policy required medications to be administered according to prescriber orders and within specified timeframes, but multiple instances were documented where insulin Lantus and Lispro were administered significantly later than ordered. For one resident, Lantus insulin scheduled for 9:00 a.m. was repeatedly given after noon, and Lispro insulin, which should be administered before meals based on blood glucose readings, was often delayed by several hours. Similar delays were observed for another resident, with both scheduled and sliding scale insulin doses administered well past the prescribed times. These delays in insulin administration were confirmed through review of medication administration records and staff interviews. One resident experienced a hypoglycemic event, with a blood glucose reading of 36, after delayed insulin administration, requiring intervention per hypoglycemic protocol and subsequent transfer to the hospital. Facility leadership acknowledged that insulin administration did not adhere to the facility's medication administration policy, resulting in significant medication errors for both residents.